VP of Claims Job in Long Beach 90745, California US
MOLINA HEALTHCARE – VP CLAIMS
POSITION SUMMARY
Under the general direction of the SVP PPI, the VP of Claims is responsible for the implementation of companywide initiatives impacting any one or more of the following areas reporting to this position:
- Claims Production (i.e. Claims Production, Audit, Production Vendor Oversight) for both the Medicaid and Medicare lines of business
- Claims Shared Services for both the Medicaid and Medicare lines of business (i.e. activities supporting the production of claims including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Corporate Encounter Team as well as providing overall organizational leadership of claims editing and recovery vendors aimed at managing overall healthcare costs)
- Corporate Operations PMO for both the Medicaid and Medicare lines of business (leading both business process changes and systems oriented projects requiring engagement with IT and other departments to implement changes to business processes and systems)
- Corporate Configuration of the QNXT system for both Medicaid and Medicare lines of business as well as the Care Management application for UM functions within QNXT:
- Meeting state regulatory requirements,
- Enabling the system to produce expected health care costs
- Maximizing MASS Adjudication within QNXT,
- Improving the quality of the provider payment process,
- Reducing GA costs as measured by both Unit Claims Costs and on a per member per month basis in each of the areas reporting to the VP, Claims as part of the enterprise wide efforts to meet or exceed budget targets and to consistently to reduce GA.
- Continuing to drive positive operational and financial outcomes within the other Provider Payment Initiatives reporting up to the SPV, PPI.
DUTIES AND RESPONSIBLITIES
- Hire, coordinate training and manage staff involved in creating controls, documents and tools within the Corporate Claims, Shared Services, Corporate Ops PMO or Configuration Teams or other Corporate Operations areas reporting to the VP, Claims in order to manage work in any of the assigned Corporate Operations areas for both the Medicaid and Medicare lines of business.
- Identify, develop, train appropriate staff and implement processes to standardize the overall end to end processing claims, as well as the configuring of within the various modules of the QNXT System for both the Medicaid and Medicare lines of business.
- Initiate staff and coordinate needed projects around various systems enhancements, conversions and upgrades. These projects will improve QNXT Claims MASS Adjudication results, enhance the Corporate Operations claims quality and reduce unit claims costs by reducing rework (both underpayments and overpayments) for both the Medicare and Medicaid lines of business.
- Identify projects/initiatives that reduce administrative costs for Molina and/or providers as well as identify opportunities to insure accurate claims editing is occurring to assist in the management of the organizational health care costs for both the Medicaid and Medicare lines of business. Included in this arena is to work with appropriate vendors to identify and initiate appropriate recovery opportunities.
- Convene work groups, develop implementation plans with identified tasks, timelines and assigned parties. Execute and measure success.
- Lead the Corporate Claims PMO and/or the team when they are leading or participating on projects throughout the organization to insure timely and effective implementation of new systems, acquisitions, or workflow processes to meet the operational and regulatory demands of the enterprise for both the Medicaid and Medicare lines of business.
- Lead the Corporate Claims Testing team to validate that systems changes and material configuration changes are tested to insure expected outcomes prior to implementation of those changes in the production environment for both the Medicaid and Medicare lines of business.
- Participate with others in the Corporate Operational Leadership Team along with IT to analyze the root cause information of variations to the claims payment to find/propose ways to improve upon performance results, identify potential risks to the organization and lead the needed systems or configuration changes within the claims process to support the organizational needs in both the Medicaid and Medicare lines of business.
- Lead the Corporate Claims Training Team in preparing needed documentation around training of new/existing staff while also assist in preparing needed Claims Payment Guidelines to assist in the timely and accurate processing of Medicaid and Medicare claims within Corporate Claims.
- Manage direct Molina staff as well as oversee vendors involved in any of the areas reporting to the VP, Claims to enable the organization to produce operational results at the lowest possible cost, the most consistent and compliant service levels and the highest level of quality for both the Medicaid and Medicare lines of business.
- Insure all state, federal and Molina regulations, Policies/Procedures and SOP’s are implemented and followed on a consistent basis to insure the highest compliance possible within the Corporate Operations areas.
- Set and manage overall costs to meet/exceed annual budgets set for each or all of the areas in Corporate Operations reporting to the VP, Claims as well as find ways to improve productivity and automation wherever possible to reduce unit costs and overall GA for the organization.
Knowledge, Skills and Abilities
- Excellent verbal and written communication skills
- Ability to influence and drive change among peers and others within the Molina organization
- Skill to envision, craft proposals, obtain consensus around approving and implementing future state processes and systems needed to support strategic direction set by organization.
- Ability to abide by Molina’s policies
- Maintain regular attendance based on agreed-upon schedule
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
QUALIFICATIONS
Required Education:
BA, Masters preferred or appropriate relevant healthcare experience (4 years for relevant BA background or 7 years for relevant Masters background)
Required Experience:
10 years Healthcare experience in related job or related Operational experience.
Molina Healthcare is an Equal Opportunity Employer M/F/D/V.
See Job Description
