Jobs at Molina Healthcare Inc.

Leads interpretation of regulatory, contractual, benefit, and claims requirements and translates them into system configuration specifications. Supports governance, implementation, testing, defect resolution, reporting, compliance, and financial-impact analysis across health plans and products. Serves as a configuration subject matter expert, leads cross-functional projects, maintains regulatory information, improves configuration standards, and trains team members in a remote, multi-time-zone environment.

Reviews and resolves provider coding-related claim denials by examining medical records, claims, denial reasons, and billing guidelines. Conducts audits, determines whether to uphold or overturn denials, communicates decisions to providers, identifies coding errors, documents findings, and collaborates across departments to support compliance and process improvements.

Leads enterprise architecture strategy, roadmaps, standards, systems integration, cloud implementations, and complex IT transformation initiatives. Provides technical leadership for enterprise rollouts, mergers and acquisitions, cross-functional programs, and scalable technology solutions. Translates business requirements into architectures, evaluates technology trends, improves processes, briefs executives, and mentors architecture teams. Requires extensive enterprise architecture, systems integration, cloud, data analysis, healthcare payer, project management, and stakeholder leadership experience.

Provides entry-level support for maintaining provider demographic, affiliation, and contract data in claims and provider databases. Loads and updates provider information in QNXT using manual and automated tools, validates records against business and system requirements, audits data for quality and financial accuracy, and ensures accurate information for claims processing, reporting, and provider directories. The role includes paid QNXT and state-specific training.

Leads the design and delivery of scalable analytics solutions using Azure Databricks, Power BI, and related platforms. Transforms and validates structured and unstructured data, applies statistical techniques, develops dashboards and analytical models, and implements data governance and quality processes. Partners with business and technology stakeholders to translate requirements into technical solutions, provides peer guidance, monitors data trends, and communicates actionable insights to technical and non-technical audiences.

Leads complex business and technology programs across the full lifecycle, coordinating multiple project teams and stakeholders. Develops integrated plans, manages dependencies, risks, scope, timelines, resources, and budgets, and tracks program KPIs. Facilitates governance meetings, communicates status and outcomes to leadership, maintains documentation, supports decision-making, and drives alignment with business priorities. May mentor team members and coordinate continuous improvement activities.

Supports provider network administration by validating, maintaining, auditing, and entering provider demographic, affiliation, fee schedule, and claims information into health plan systems. Reviews data for accuracy, resolves configuration issues with internal teams, provides documented quality feedback, and assists with provider network projects while meeting deadlines and business requirements.

Reviews healthcare contracts and claims to validate QNXT configuration, provider contracts, benefits, fee schedules, coding, reimbursements, and payment accuracy. Audits claims for processing errors, fraud, waste, overpayments, and regulatory compliance. Documents findings, maintains audit workbooks, tracks follow-up actions, interprets state and federal requirements, and recommends system or process improvements to stakeholders and management.

Leads engineering support and architecture for enterprise-scale healthcare data platforms on Azure. Designs Databricks, Synapse, Data Factory, and Data Lake solutions; builds batch and real-time pipelines, analytical data models, BI solutions, and automated data quality frameworks. Implements machine learning and AI-assisted development, integrates low-code systems, ensures HIPAA compliance, and translates business needs into technical solutions. Mentors engineers, resolves technical issues, supports Agile delivery, and partners with healthcare business leaders on Medicare and Medicaid analytics initiatives.

Leads cross-functional process improvement and operational excellence initiatives across healthcare member, provider, sales, agent, and campaign operations. Serves as a Salesforce subject-matter expert, supporting CRM workflows, integrations, requirements, testing, reporting, and production validation. Partners with Genesys, analytics, technology, product, vendor, and business teams to identify process gaps, define future-state workflows, improve data integrity, and deliver measurable operational outcomes.

Researches medical claims to identify processing errors, interpret regulatory and contractual requirements, and ensure accurate, compliant reprocessing. Performs root-cause analysis, develops remediation plans, monitors claims through resolution, tailors reports, and presents findings to leadership and operations teams. Coordinates complex claims projects with internal and external stakeholders, supports provider and member inquiries, updates procedures, and helps improve claims-processing efficiency.

Reviews and resolves member and provider claims appeals, disputes, grievances, and complaints. Researches medical records, claims guidelines, contracts, benefits, fee schedules, and system configurations to determine outcomes and identify payment errors. Prepares compliant correspondence, appeal summaries, and provider reconsideration responses while meeting regulatory and departmental timelines. Communicates resolutions to members, providers, and authorized representatives and documents findings accurately.

Reviews and resolves member and provider appeals, grievances, disputes, and complaints within CMS, state, federal, and company timelines. Researches claims, medical records, contracts, benefits, fee schedules, and system configurations to determine outcomes and root causes of payment errors. Prepares accurate appeal summaries and regulatory correspondence, communicates resolutions, processes reconsideration requests, and documents findings while meeting production standards.

Reviews and resolves member and provider appeals, grievances, disputes, and claims complaints. Researches medical records, claims guidelines, contracts, benefits, fee schedules, and system configurations to determine outcomes and payment-error root causes. Prepares compliant appeal summaries, correspondence, claim adjustments, and responses while meeting regulatory and departmental production timelines. Communicates resolutions to members, providers, and authorized representatives.

Analyzes and interprets regulatory and functional requirements for health plan coverage, reimbursement, and processing systems. Develops requirement documentation, monitors policy updates, coordinates stakeholder reviews, supports governance committees, investigates compliance-related root causes, and communicates impacts to health plans, product teams, and leadership. Maintains regulatory data, supports issue resolution, and ensures traceability of requirement changes across business functions.

Analyzes healthcare claims, pharmacy, laboratory, financial, utilization, and risk-adjustment data. Develops suspect, targeting, tracking, QA, and reporting systems for Medicaid, Marketplace, Medicare, and MMP interventions. Performs predictive modeling, statistical analysis, forecasting, anomaly detection, data validation, root-cause analysis, and risk-score tracking. Communicates analytical findings to technical and nontechnical stakeholders while supporting cross-functional projects and regulatory or business requests.

Manages payment integrity programs and recovery operations, overseeing staff, quality assurance, performance metrics, workflows, vendor relationships, regulatory compliance, and process improvement. Analyzes operational data to improve recovery effectiveness, cost avoidance, accuracy, and audit readiness while supporting CMS and state requirements.

Leads complex, cross-functional business programs and strategic initiatives from planning through implementation and operational transition. Manages scope, schedules, budgets, resources, dependencies, risks, vendors, documentation, compliance, and stakeholder alignment. Partners with healthcare, clinical, operational, compliance, finance, network, and technology teams to translate business requirements into operational solutions and deliver enterprise-wide transformation initiatives.

Manages national healthcare quality performance initiatives, including quality data collection, analytics, reporting, validation, HEDIS audit readiness, and care-gap improvement. Coordinates cross-functional stakeholders, vendors, project deliverables, regulatory compliance, documentation, and status reporting. Requires healthcare quality knowledge, data analysis skills, and experience managing quality programs or projects. Familiarity with Azure, SQL, NCQA, HEDIS, CMS, healthcare coding systems, and managed care operations is preferred.

Leads national healthcare quality performance initiatives, including HEDIS targeting and reporting, quality analytics, forecasting, regulatory compliance, data ingestion, audit readiness, and care-gap improvement. Manages program deliverables, timelines, resources, risks, and stakeholder communications across a matrixed organization. Analyzes healthcare data, supports EHR and HIE data strategies, develops reporting and documentation, and provides subject matter guidance to quality teams.