Job Summary

We are seeking a highly experienced Lead Analyst, Configuration Oversight to support our Payment Integrity and Claims Operations teams in ensuring the accuracy and compliance of Coordination of Benefits (COB) claim pricing and processing. This role will focus on identifying, reviewing, and validating Medicaid secondary payments to ensure alignment with internal configuration rules and regulatory guidance. The ideal candidate will bring deep knowledge of claims adjudication, QNXT system navigation, and strong analytical acumen. Experience in Medicaid managed care is required, and a background in payment integrity-either at a health plan or vendor-is strongly preferred.

Knowledge/Skills/Abilities

Review Medicaid COB claims for correct secondary pricing logic and compliance with configuration and regulatory rules.

Analyze claim outcomes and identify trends or discrepancies related to over- or underpayment.

Utilize QNXT to research claims history, provider contract setup, and benefits configuration.

Work cross-functionally with Configuration, Claims, and Payment Integrity teams to resolve identified issues.

Support audits, validations, and root cause analysis tied to COB and TPL processing logic.

Assist in developing and refining internal SOPs and audit tools related to COB claim reviews.

Act as subject matter expert for Medicaid COB claim adjudication, configuration testing, and QNXT setup validation.

Provide training, mentorship, or oversight support to junior analysts, as needed.

Utilizes SQL to pull data for review and distribution.

Accurately interprets end to end business requirements and able to confirm outcomes meet the specific state/federal requirements.

Assists manager in establishing standards, guidelines, and best practices for the audit team

Interprets and validates accuracy of complex reports and automated configuration processes/solutions

Assist manager in establishing peer review standards and methodology

Research and review new audit tools and techniques and provide recommendations to management

Validates accuracy of new complex configuration processes/solutions

Interprets complex business problems and technical issues

Effectively communicates audit findings and/or outcomes through review meetings, written communications, and, workflow diagrams.

Helps drive solution to successful implementation by directing technical and business resources during all phases of the software development life cycle

Gains a deep understanding of Molina claims life cycle and all processes that affect claims payment

Participates in or leads project meetings

Writes Requirements for BRDs/FRDs and Reports without needing mentoring

Suggests schema/solution. Works with technical resource to determine best solution.

Manages complex projects from requirements to deployment, including work assignment, prioritization, issue triage etc.

Researches complex issues

Job Qualifications

REQUIRED EDUCATION:

Associates Degree or equivalent combination of education and experience

REQUIRED EXPERIENCE:

5 + years of experience with oversight, auditing, government regulations/compliance, operations

Must have strong understanding of QNXT claims processes

Must be able to identify and troubleshoot claim discrepancies by utilizing benefit and provider contracts, regulatory requirements and various claims related resources

Strong experience using Microsoft Office applications such as Excel, Word, Outlook, Powerpoint and Teams

Effective written and verbal communication skills.

Flexibility to meet changing business requirements, strong commitment to high quality, on time delivery

Previous process improvement experience

Previous experience mentoring or training peers

PREFERRED EDUCATION and experince:

Bachelor's Degree or equivalent experience

Prior experience in Payment Integrity and/or COB/Claims roles at a health plan or vendor.

Familiarity with claim recovery audits and regulatory reporting requirements (Medicaid).

Exposure to EDI transactions (837, 835) and COB data exchange protocols.

Experience with SQL.

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $155,508 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.