Jobs at Molina Healthcare Inc.

Own and prioritize the HEDIS Engine and clinical data ingestion products end-to-end. Define product vision, maintain backlog, write user stories, lead Agile ceremonies, accept delivered work, ensure regulatory/compliance alignment, mitigate delivery risks, and collaborate with engineering, data, QA, operations, and health plan stakeholders.

Entry-level analyst responsible for accurate loading, updating, and auditing of provider demographic and contract data across claims systems and provider databases to ensure correct claims processing, reporting, and directories.

Review, research, and resolve member and provider appeals, grievances, and claims denials in accordance with CMS, state, and Molina guidelines; communicate outcomes, prepare correspondence and summaries, request and review medical records, and identify root causes of payment errors.

Manage process improvement, organizational change, and project delivery including estimating, scheduling, costing, planning, and risk/issue management. Develop detailed project and communication plans, define roles, and use project-specific software. Support intermediate to large-scale projects with cross-functional teams and present alternatives to overcome obstacles.

Support compliance operations by managing Corrective Action Plans (CAPs) from initiation to remediation, analyze root causes and regulatory requirements, coordinate with business areas and regulators, maintain KPI and compliance reporting, interpret federal/state regulations, and manage compliance systems and CMS access.

Lead competitive intelligence and market analysis for RFP capture and response efforts across Medicaid, DSNP, and Marketplace lines. Build and maintain competitor content/scoring databases, support pre-RFP capture strategy, advise senior leadership, collaborate cross-functionally, support legal during award protests, and provide coaching for oral presentations. Travel 50%+.

Analyze healthcare and operational datasets to produce and maintain reports, dashboards, and analytics using SQL, Excel, and BI tools. Validate data, document workflows, support regulatory reporting, and collaborate with stakeholders to deliver insights for utilization, cost containment, and performance improvement.

Lead cross-functional business programs from initiation through delivery: plan schedules and budgets, manage program staff and vendors, define requirements, create test plans and training materials, recommend process improvements, and monitor program performance. Acts as subject matter expert and supports Program Managers to meet critical organizational needs.

Lead a team overseeing operational controls, audits, compliance, and corrective actions across corporate operations. Liaise with regulators and auditors, manage CAPs, ensure regulatory alignment across states, support SIU and legal, and drive operational performance and improvement. Hire, train, and manage staff and may oversee financial/performance results for select operational units.

Manage and supervise a configuration oversight team performing claims audits, ensuring timely, compliant audits and corrective actions. Liaise with stakeholders, develop policies/procedures, identify and mitigate regulatory risks, produce reports, and lead performance improvement and training activities.

Designs and develops custom health plan reports for Risk and Quality/HEDIS, builds intervention and ad hoc reports, performs data analysis and QA using Databricks SQL, Power BI and Excel, conducts root cause analysis, tests data warehouse changes, and supports performance improvement projects.

Perform ongoing compliance audits to evaluate adherence to federal and state regulations, internal policies, and contract provisions; identify gaps, document findings, recommend corrective actions, and support risk assessment and monitoring of remediation.

Lead Databricks-based enterprise data and analytics modernization programs. Define future-state architecture, drive platform modernization, ensure security, scalability, cost optimization, and mentor teams while delivering AI-ready data platforms and governance.

Lead a finance and analytics team to perform financial modeling, forecasting, variance analysis, reserve review, vendor contract evaluation, and reporting. Collaborate with cross-functional teams, regulatory bodies, and enterprise analytics to improve profitability, data quality, and performance monitoring while supporting strategic planning and financial compliance.

Lead-level role supporting core operations: manage escalations, troubleshoot enrollment and claims issues, coordinate staffing and workflows, drive quality improvements, and provide SME guidance, training, and mentoring to team members.

Perform contract and targeted claim audits in QNXT to validate claim and provider data, ensure contracts and configurations are correct, identify coding or payment errors, track and report audit findings, recommend configuration or process changes, and collaborate with stakeholders to implement corrections.

Lead and manage programs delivering CMS/HPMS submissions and network adequacy activities. Coordinate cross-functional teams and vendors, oversee regulatory documentation in Inovarre, create business requirements, test plans, and training materials, and drive process improvements while monitoring schedules, budgets, and program delivery.

Supports prepay payment integrity by performing chart reviews, abstracting diagnosis codes per HCC, validating coding rationale, monitoring savings and accuracy trends, and resolving coding edit inquiries. Partners with providers, vendors, and internal teams to train on risk adjustment best practices, create educational materials, coordinate CMS data validation, and support implementation projects across finance, claims, and clinical stakeholders.

Designs and develops reporting solutions for HEDIS auditing, rate tracking, and performance metric tracking. Collects, validates, analyzes managed care data (claims, pharmacy, lab), builds QA and medical record review reports, supports predictive intervention analytics, conducts root-cause analysis, and communicates findings to stakeholders to drive quality improvement.

Provide senior-level support for HEDIS and quality improvement abstraction, collect and review medical records, load data into HEDIS applications, ensure compliance with NCQA/HEDIS specifications, participate in audits and vendor coordination, and mentor/train abstraction team members.