Director Core Systems Strategies – QNXT/NetworX

Job Overview

Job Summary Leads and directs team responsible for configuration activities including accurate and timely implementation and maintenance of critical information on claims databases, validation of data stored on databases, and adherence to health plan business and system requirements as it pertains to contracting, benefits, prior authorizations, fee schedules and other business requirements.

Essential Job Duties • Directs configuration team, and demonstrates accountability for team performance - including meeting or exceeding established performance targets; targets may be based upon specific health plan requirements, and/or federal/state requirements.

Job Description

• Strategically plans, leads, and manages configuration workflow processes.

• Continuously identifies and executes opportunities for operational efficiencies and develops best practice approaches for assigned operational areas, ensuring achievement of organizational/department goals.

• Ensures appropriate resources are available to achieve department goals - escalates resource needs, rationale, and deficiencies to leadership.

• Identifies and implements strategic process improvements related to the configuration function that demonstrate return on investment (ROI).

• Establishes and maintains benefits, provider contracts, fee schedules, claims edits, and other system settings in the claim payment system. • Directs the development and implementation of contract, benefit configuration, and fee schedules.

• Directs the implementation and maintenance of member benefits in the claims payment system and other applicable systems. • Supports critical business strategies by providing systematic solutions and or recommendations on business processes.

Key Responsibilities

• Job Summary Leads and directs team responsible for configuration activities including accurate and timely implementation and maintenance of critical information on claims databases, validation of data stored on databases, and adherence to health plan business and system requirements as it pertains to contracting, benefits, prior authorizations, fee schedules and other business requirements.
• Essential Job Duties • Directs configuration team, and demonstrates accountability for team performance - including meeting or exceeding established performance targets; targets may be based upon specific health plan requirements, and/or federal/state requirements.
• Strategically plans, leads, and manages configuration workflow processes.
• Ensures appropriate resources are available to achieve department goals - escalates resource needs, rationale, and deficiencies to leadership.
• Supports critical business strategies by providing systematic solutions and or recommendations on business processes.
• Builds and maintains strong trusted relationships with key stakeholders including health plan leadership and other cross-functional departments; presents data and opportunities to stakeholders and collaborates on performance improvement initiatives.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of configuration/department-specific goals.
• Required Qualifications • At least 8 years of configuration oversight, claims, auditing, and/or health care operations experience in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.

Required Skills and Qualifications

• Required Qualifications • At least 8 years of configuration oversight, claims, auditing, and/or health care operations experience in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Strong analytical, critical-thinking, and problem-solving skills.
• Strong multitasking ability, and decision-making skills.
• Excellent verbal and written communication skills.
• Preferred Qualifications • Certified Professional Coder (CPC).
• Extensive experience leading analysis and operational teams in a managed care setting.
• Extensive experience collaborating with various levels of leadership in a highly matrixed organization.

Benefits and Perks

• Job Summary Leads and directs team responsible for configuration activities including accurate and timely implementation and maintenance of critical information on claims databases, validation of data stored on databases, and adherence to health plan business and system requirements as it pertains to contracting, benefits, prior authorizations, fee schedules and other business requirements.
• Establishes and maintains benefits, provider contracts, fee schedules, claims edits, and other system settings in the claim payment system.
• Directs the development and implementation of contract, benefit configuration, and fee schedules.
• Directs the implementation and maintenance of member benefits in the claims payment system and other applicable systems.
• Advanced ability to identify and troubleshoot claim discrepancies by utilizing benefit and provider contracts, regulatory requirements and various claims related resources.
• Molina Healthcare offers a competitive benefits and compensation package.

Work Location and Schedule

This role is listed as Remote USA with location information shown as Remote USA. The employment type is Full Time.

About the Company

Molina Healthcare is the organization connected with this listing. USA Jobs Today displays this opportunity for job discovery only, so applicants should verify company details, application instructions, and eligibility on the official employer website.