Analyzes healthcare claims, reimbursement policies, medical billing, and coding requirements to identify payment integrity overpayment opportunities. Researches CMS, NCCI, Medicare, Medicaid, and state guidance, then translates findings into claims edits, recovery concepts, coding criteria, and detailed business requirements for analytics and technical teams.
JOB DESCRIPTION
Job Summary
This position supports Payment Integrity through the research and development of post-pay recovery concepts and claims edits. The role analyzes healthcare claims, medical billing and coding requirements, and reimbursement policies to identify potential overpayment opportunities and translate findings into clearly defined business requirements for technical implementation.
JOB DUTIES
- Researches and develops post-pay Payment Integrity recovery concepts and claims edits by evaluating healthcare claims, reimbursement patterns, medical billing and coding requirements, and applicable regulatory and payer guidance.
- Researches and interprets CMS, NCCI, state Medicaid, Medicare, and other applicable reimbursement and coding requirements to support development of defensible claims-recovery logic.
- Translates identified Payment Integrity opportunities into detailed business requirements, including claim logic, coding criteria, inclusions, exclusions, and supporting documentation for analytic and technical development teams.
KNOWLEDGE/SKILLS/ABILITIES
- Working knowledge of healthcare claims, medical billing, reimbursement methodologies, and coding systems including CPT, HCPCS, ICD-10, revenue codes, modifiers, and claim types.
- Ability to research reimbursement and coding policies and translate policy requirements into actionable claims logic and business requirements.
- Ability to analyze claims data to identify billing patterns, potential overpayments, and opportunities for Payment Integrity recovery concepts.
JOB QUALIFICATIONS
Required Qualifications
- At least 2 years of experience in previous roles in a managed care organization, health insurance or directly adjacent field, or equivalent combination of relevant education and experience.
- Policy/government legislative review knowledge.
- Strong analytical and problem-solving skills.
- Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams.
- Previous success in a dynamic and autonomous work environment.
Preferred Qualifications
- Experience working with healthcare claims, medical billing/coding, reimbursement, payment integrity, claims auditing, or an equivalent claims-focused function.
- Payment Integrity or post-pay claims recovery experience.
- Experience developing or supporting claims edits, payment policies, recovery concepts, or reimbursement rules.
- Experience with CMS, NCCI, Medicare, Medicaid, and/or state-specific reimbursement guidance.
- Medical coding certification such as CPC, CCS, COC, or equivalent.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
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