Presbyterian jobs in Santa Fe, NM - 81 jobs

Provides customer service support for inbound/outbound pharmacy calls from members, providers, and pharmacies. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Shift Available:12:30-9 PM MST Essential Job Duties * Handles and records inbound/outbound pharmacy calls from members, providers and pharmacies in accordance with departmental policies, state regulations, National Committee of Quality Assurance (NCQA) guidelines, and Centers for Medicare and Medicaid Services (CMS) standards. * Provides coordination and processing of pharmacy prior authorization requests and/or appeals. * Explains point-of-sale claims adjudication, state, NCQA and CMS policies/guidelines, and any other necessary information to providers, members and pharmacies. * Assists with clerical tasks and other day-to-day pharmacy call center operations as delegated. * Effectively communicates plan benefit information, including but not limited to: formulary information, copay amounts, pharmacy location services and prior authorization outcomes. * Assists members and providers with initiating verbal and written coverage determinations and appeals. * Records calls accurately within the pharmacy call tracking system. * Maintains established pharmacy call quality and quantity standards. * Interacts with appropriate primary care providers to ensure member registry is current and accurate. * Supports pharmacists with completion of comprehensive medication reviews (CMRs)through pre-work up to case preparation. * Proactively identifies ways to improve pharmacy call center member relations. Required Qualifications * At least 1 year related experience, including call center or customer service experience, or equivalent combination of relevant education and experience. * Excellent customer service skills. * Ability to work independently when assigned special projects, such as pill box requests, case management referrals, over the counter (OTC) requests, etc. * Ability to multi-task applications while speaking with members. * Ability to multi-task applications while speaking with members. * Ability to develop and maintain positive and effective work relationships with coworkers, clients, members, providers, regulatory agencies, and vendors. * Ability to meet established deadlines. * Ability to function independently and manage multiple projects. * Excellent verbal and written communication skills, including excellent phone etiquette. * Microsoft Office suite (including Excel), and applicable software program(s) proficiency. Preferred Qualifications * Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. * Health care industry experience. 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 Pay Range: $21.65 - $28.82 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

**JOB DESCRIPTION** **Job Summary** Designs and implements processes and solutions associated with a wide variety of data sets used for data/text mining, analysis, modeling, and predicting to enable informed business decisions. Gains insight into key business problems and deliverables by applying statistical analysis techniques to examine structured and unstructured data from multiple disparate sources. Collaborates across departments and with customers to define requirements and understand business problems. Uses advanced mathematical, statistical, querying, and reporting methods to develop solutions. Develops information tools, algorithms, dashboards, and queries to monitor and improve business performance. Creates solutions from initial concept to fully tested production, and communicates results to a broad range of audiences. Effectively uses current and emerging technologies. **KNOWLEDGE/SKILLS/ABILITIES** + Extracts and compiles various sources of information and large data sets from various systems to identify and analyze outliers. + Sets up process for monitoring, tracking, and trending department data. + Prepares any state mandated reports and analysis. + Works with internal, external and enterprise clients as needed to research, develop, and document new standard reports or processes. + Implements and uses the analytics software and systems to support the departments goals. **JOB QUALIFICATIONS** **Required Education** Associate's Degree or equivalent combination of education and experience **Required Experience** 1-3 years **Preferred Education** Bachelor's Degree or equivalent combination of education and experience **Preferred Experience** 3-5 years 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: $80,168 - $116,835 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for coordination of benefits review activities that directly impact medical expenses and premium reimbursement. Responsible for primarily coordinating benefits with other carriers responsible for payment. Facilitates administrative support, data entry, and accurate maintenance of other insurance records. Job Duties * Provides telephone, administrative and data entry support for the coordination of benefits (COB) team. * Phones or utilizes other insurance company portals to validate state, vendor, and internal COB leads. * Updates the other insurance table on the claims transactional system and COB tracking database. * Review of claims identified for overpayment recovery. Job Qualifications REQUIRED QUALIFICATIONS: * At least 1 year of administrative support experience, or equivalent combination of relevant education and experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Ability to work cross-collaboratively across a highly matrixed organization and establish and maintain effective relationships with internal and external stakeholders. * Microsoft Office suite proficiency. PREFERRED QUALIFICATIONS: * Health care experience 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. Pay Range: $21.65 - $31.71 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Leads a regional team of medical directors and clinical staff, providing psychiatric oversight and expertise in the medical necessity, appropriateness, and quality of behavioral health services (mental health and substance use disorders) across multiple states. Ensure members receive clinically appropriate, evidence-based care in the most effective setting while contributing to enterprise-wide strategies for integrated behavioral health programs, utilization management standardization, and cost-effective quality outcomes in a managed care environment. Contributes to overarching strategy to provide quality and cost-effective member care. **Essential Job Duties** + Leads and manages a team of medical directors and behavioral health clinicians responsible for prior authorization, inpatient concurrent review, discharge planning, care management, and interdisciplinary care team activities across a designated multi-state region. + Provides psychiatric leadership and clinical expertise for utilization management, case management, and integrated behavioral health/chemical dependency programs; collaborates with regional and enterprise leadership to standardize policies and procedures. + Recruits, hires, trains, mentors, and develops medical director staff and team members as needed. + Ensures authorization decisions are rendered by qualified personnel without influence from fiscal or administrative incentives, in compliance with regulatory and accreditation standards. + Analyzes regional data to identify behavioral health cost-savings opportunities, quality improvements, and utilization trends (e.g., prior authorizations, outlier management). + Facilitates regional medical necessity reviews, cross-coverage, and responses to state-specific regulatory inquiries, complaints, or requests for proposals (RFPs). + Contributes to the development and implementation of behavioral health medical policies, peer review processes, provider education, and contract reviews. + Represents the organization in regional stakeholder engagements, including state regulators, providers, and advocacy groups. + Conducts peer reviews and supports fraud, waste, and abuse mitigation efforts. **Job Qualifications** **Required Qualifications** + Doctor of Medicine (MD) or Doctor of Osteopathy (DO), with board certification in Psychiatry or a related behavioral health specialty. + Medical license in at least one state (CA, UT/ID, WA, NV or AZ) within the assigned region. License must be active and unrestricted in state of practice. + At least 8 years of relevant experience, including clinical practice in behavioral health and at least 3 years as a medical director in a managed care setting supporting utilization management and quality initiatives. + At least 3 years management/leadership experience. + Demonstrated experience in multi-state or regional operations, such as standardizing utilization management policies across health plans or navigating varied state Medicaid/Medicare regulations. + Working knowledge of national, state, and local laws; regulatory requirements (e.g., NCQA, HEDIS); and evidence-based clinical criteria for behavioral health. + Proven ability to lead in a highly matrixed organization, build consensus, and make strategic decisions. Available to work, Mon-Fri, Pacific or Mountain Time Zone. + Strong verbal and written communication skills, with proficiency in Microsoft Office suite and applicable clinical software systems. **Preferred Qualifications** + Eligibility for multi-state licensure. 5 years in behavioral health-specific managed care leadership. + Experience with value-based contracting, fraud/waste/abuse mitigation, integrated behavioral-physical health services, or tools such as MCG/InterQual guidelines and PEGA systems. + Certifications in healthcare management (e.g., CPE) or advanced degrees (e.g., MBA). 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. Pay Range: $214,132 - $417,557 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides senior level support for accurate and timely intake and interpretation of regulatory and/or functional requirements related to but not limited to coverage, reimbursement, and processing functions to support systems solutions development and maintenance. This role includes coordination with stakeholders and subject matter experts on partnering teams and supporting governance committees where applicable. JOB DUTIES * Develops and maintains requirement documents related to coverage, reimbursement and other applicable system changes in areas to ensure alignment to regulatory baseline requirements and any health plan/product team developed requirements. * Monitors regulatory sources to ensure all updates are aligned as well as work with operational leaders within the business to provide recommendations for process improvements and opportunities for cost savings. * Leads coordinated development and ongoing management /interpretation review process, committee structure and timing with key partner organizations. Interpret customer business needs and translate them into application and operational requirements. * Communicates requirement interpretations and changes to health plans/product team and various impacted corporate core functional areas for requirement interpretation alignment and approvals as well as solution traceability through regular meetings and other operational process best practices. * Where applicable, codifies the requirements for system configuration alignment and interpretation. * Provides support for requirement interpretation inconsistencies and complaints. * Assists with the development of requirement solution standards and best practices while suggesting improvement processes to consistently apply requirements across states and products where possible. * Self-organized reporting to ensure health plans/product team and other leadership are aware of work efforts and impact for any prospective or retrospective requirement changes that can impact financials. * Coordinates with relevant teams for analysis, impact and implementation of changes that impact the product. * Engages with operations leadership and Plan Support functions to review compliance-based issues for benefit planning purposes. KNOWLEDGE/SKILLS/ABILITIES * Maintains relationships with Health Plans/Product Team and Corporate Operations to ensure all end-to-end business requirements have been documented and interpretation are agreed on and clear for solutioning. * Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas. * Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company. * Ability to concisely synthesize large and complex requirements. * Ability to organize and maintain regulatory data including real-time policy changes. * Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems. * Ability to work independently in a remote environment. * Ability to work with those in other time zones than your own. JOB QUALIFICATIONS Required Qualifications * At least 4 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 * Familiarity with administration systems * Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams * Previous success in a dynamic and autonomous work environment Preferred Qualifications * Project implementation experience * Knowledge and experience with federal regulatory policy resources including Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA). * Medical Coding certification. 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. Pay Range: $80,168 - $128,519 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Provides support for accounts payable activities including processing invoices/payments and ensuring disbursements are made under proper financial controls, while maximizing cash flow opportunities. - Generates timely release of payments through the provider payment system, trade payables system and expense management system. - Facilitates efficient and accurate processing of high-volume payables within the payable system, and ensures compliance with company payables policy. - Processes and validates the set-up of vendors, maintains vendor database, and assists in 1099 distribution. - Researches and reconciles payable reports, prepares files, and remits escheat payments to the state. - Independently resolves errors that occur during processing by collaborating directly with information technology (IT) teams and health plans. **Required Qualifications** - At least 1 year of related payables experience, or equivalent combination of relevant education and experience. - Experience processing and distributing payments in a timely manner. - Experience ensuring company invoices, check requests and expense reports are handled accurately. - Knowledge of accounts payable process e.g., 3-way match vouchering. - Organizational skills and ability to manage time effectively. - Effective verbal and written communication skills. - Proficient in Microsoft Office suite products, key skills in Excel (VLOOKUPs and pivot tables)/applicable software program(s) proficiency. **Preferred Qualifications** - Associate's degree in accounting, finance or business. 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 Pay Range: $21.65 - $34.88 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims. * Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution. * Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. * Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. * Assists in reviews of state and federal complaints related to claims. * Collaborates with other internal departments to determine appropriate resolution of claims issues. * Researches claims tracers, adjustments, and resubmissions of claims. * Adjudicates or readjudicates high volumes of claims in a timely manner. * Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership. * Meets claims department quality and production standards. * Supports claims department initiatives to improve overall claims function efficiency. * Completes basic claims projects as assigned. Required Qualifications * At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. * Research and data analysis skills. * Organizational skills and attention to detail. * Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. * Customer service experience. * Effective verbal and written communication skills. * Microsoft Office suite and applicable software programs proficiency. 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 Pay Range: $21.65 - $38.37 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion within Provider Network department. Help facilitate corporate markets with obtaining SAI goals. Plans and directs schedules as well as project budgets. Monitors the project from inception through delivery. May engage and oversee the work of external vendors. Assigns, directs and monitors system analysis and program staff. These positions' primary focus is project/program management. Job Duties * Provide project summaries that will be senior leadership facing with ties to market SAI goals. * Active collaborator with people who are responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion. * Plans and directs schedules as well as project budgets. * Monitors the project from inception through delivery. * May engage and oversee the work of external vendors. * Focuses on process improvement, organizational change management, program management and other processes relative to the business. * Leads and manages team in planning and executing business programs. * Serves as the subject matter expert in the functional area and leads programs to meet critical needs. * Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements. Delivers the appropriate artifacts as needed. * Works with operational leaders within the business to provide recommendations on opportunities for process improvements. * Creates business requirements documents, test plans, requirements traceability matrix, user training materials and other related documentations. * Generate and distribute standard reports on schedule JOB QUALIFICATIONS REQUIRED EDUCATION: Bachelor's Degree or equivalent combination of education and experience. REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: * 3-5 years of Program and/or Project management experience. * Operational Process Improvement experience. * Healthcare experience. * Experience with Microsoft Project and Visio. * Excellent presentation and communication skills. * Experience partnering with different levels of leadership across the organization. PREFERRED EDUCATION: Graduate Degree or equivalent combination of education and experience. PREFERRED EXPERIENCE: * 5-7 years of Program and/or Project management experience. * Provider Network and SAI * Excel and PowerPoint * Managed Care experience. * Experience working in a cross functional highly matrixed organization. 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: $80,168 - $155,508 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Join our team as an Emergency Medicine Physician in Santa Fe, NM, and lead the way in patient care. We believe in bringing "better" to our local community in Santa Fe -better care, better collaboration, and a deep commitment to the people we serve. If you're looking for a role that supports your professional growth and your connection to a vibrant community, we'd love to talk. People First in Santa Fe, NM Local Team Collaboration: * Join our close-knit team of 8 physicians and 2 APPs at Presbyterian Santa Fe. * Work alongside our dedicated providers, committed to providing patient-centered care in collaboration with all stakeholders in a positive manner. Qualifications: * Candidates eligible for consideration must have emergency medicine training. They should be board-certified in internal medicine or family medicine or eligible, except for obtaining certification. * Certifications Required: BLS, ACLS, PALS, and ATLS Practice in the Heart of the Community Scheduling: APP coverage: * Monday and Tuesday from 9 am-7 pm, and 4 pm-12 am * Wednesday to Sunday, 10 am to 10 pm. Physician coverage: * Physician coverage is provided seven days a week with shifts from 7 am to 3 pm, 2 pm to 11 pm, and 10 pm to 7 am. * The monthly workload for full-time positions is 120 hours, while part-time entails 80 hours per month. Key Responsibilities: * There are 20 beds dedicated to the ER and four additional beds allocated for the ICU. * The EM team is trained to respond to codes. * The hospitalist team is part of the Rapid Response and code team. * EPIC is our EMR. Living and working in Santa Fe * From breathtaking sunsets to a rich history and cultural scene, Santa Fe offers a blend of outdoor adventures, culinary experiences, and artistic inspiration. Moving to Santa Fe is a lifestyle shift toward outdoor living, creative pursuits, and community. * Whether one is captivated by Santa Fe's unique architecture, scenic trails, or world-renowned cuisine, there's something here for everyone. * Santa Fe's climate is a standout, offering an average of 300 days of sunshine each year. Its high-desert environment and altitude of 7,000 feet provide four distinct seasons that allow residents to enjoy the best of every type of weather. Purpose-Driven Work with Local Impact Plainview-Centered Care: Our guiding principle is patient-first care, which means we focus on the people of Santa Fe and nearby areas. You'll be part of a team that's making a real difference in the health of our neighbors. Rewards and Benefits: * Compensation: Competitive W2 compensation * Benefits: * Comprehensive benefits package, including medical, dental, vision, and life insurance. * Relocation allowance and a robust commencement bonus. * 401k with matching contributions. * Paid malpractice, including tail coverage. * Annual CME allowance. Tagged as: Physician

The Lead, Risk Adjustment - Predictive Analytics role supports Molina's Risk Adjustment Predictive Analytics team. Designs and develops Suspect, Targeting, and Tracking System to support Molina's Prospective and Retrospective Interventions. Provides technical, functional and business training to other team members to enable them to perform the tasks required. Knowledge/Skills/Abilities * Assist Risk Adjustment Data Analytics Leaders in Prospective and Retrospective Intervention Strategy Analytics along with corresponding tracking of progress and impact of such interventions. * Design and development ad-hoc as well as automated analytical modules related to Risk Adjustment for Medicaid, Marketplace and Medicare/MMP. * Assist Risk Adjustment Data Analytics Leaders in designing and developing Automated Suspect and Target/Ranking Engine for all line of businesses. * Analysis and reporting related to Managed care data like Medical Claims, Pharmacy, Lab and related financial data like risk score, revenue and cost. * Conduct root cause analysis for business data issues, report to leadership the summary of findings and resolutions. * Design and lead development of tracking system for risk scores for all intervention outcome and for overall markets and LOB. * Work in an agile business environment to derive meaningful information out of complex as well as large organizational data sets through data analysis, data mining, verification, scrubbing, and root cause analysis. * Work directly with interdepartmental / intradepartmental stakeholders along with Molina Executives to establish/deliver/explain the business requirement as well as data/data points and do necessary escalation as required. * Analyze data sets and trends for anomalies, outliers, trend changes and opportunities, using statistical tools and techniques to determine significance and relevance. Utilize extrapolation, interpolation and other statistical methodologies to predict future trends in cost, utilization and performance. Provide executive summary of findings to requestors. * Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations. * Act as a subject matter expertise by following CMS/State regulations related to Risk adjustment Analytics and provide training as required. Stay current with industry regulation changes and educate the team and management as necessary. * Track, Facilitate and Manage changes in the Datawarehouse platform and perform transparent upgrades to analytics reporting modules to ensure no impact to the end users. * Conduct preliminary and post impact analyses for any logic and source code changes for data analytics and reporting module keeping other variables as constant that are not of focus. * Develop training modules to help analysts understand processes, solutions or designs to meet the customer request for new/existing staff. * Provide technical, functional and business training to other team members to enable them to perform the tasks required. * Maintain a team culture to adopt fast faced agile environment and foster a positive attitude to take on challenging and time sensitive projects. * Take accountability of tasks and projects assigned. Job Qualifications Required Education Bachelor's Degree in Computer Science, Finance, Math or Economics or equivalent discipline. Required Experience * 6+ Years of experience in working with data mapping, scrubbing, scrapping, and cleaning of data. * 5+ Years of experience in Managed Care Organization executing similar techno functional role that involves writing complex SQL Queries, Functions, Procedures and Data design * 5+ years of experience in working with Microsoft T-SQL, SSIS and SSRS. * Familiarity with Data Science Techniques and languages like Python and R programming would be an added advantage. * 5+ Years of experience in Analysis related to Risk Scores, Encounter Submissions, Payment Models for at least one line of business among Medicaid, Marketplace and Medicare/MMP. * 5+ Years of experience in Prospective/Retrospective/Audit targeting Analytics and Reporting. * 5+ Years of experience in working with increasingly complex data problems in quantifying, measuring, and analyzing financial/performance management and utilization metrics. * 5+ Years of experience in Statistical Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions 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: $80,412 - $188,164 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Leads and supervises a team of pharmacy call center representatives and operations staff responsible to ensure that members have access to medically necessary prescription drugs. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties * Hires, trains, develops, and supervises a team of pharmacy service representatives supporting processes involved with Medicare Stars and Pharmacy quality operations. * Ensures that average phone call handle time, average speed to answer, and average hold time are compliant with Centers for Medicare and Medicaid Services (CMS) regulations. * Ensures that adequate staffing coverage is present at all times of operation. * Assists pharmacy leadership with monitoring and oversight of Molina's contracted Pharmacy Benefit Manager (PBM) for pharmacy contractually delegated functions. * Responsible for key performance indicators (KPI) reporting to department leadership on a monthly basis. * Participates, researches, and validates materials for both internal and external program audits. * Acts as liaison to internal and external customers to ensure prompt resolution of identified issues. * Assists pharmacy leadership in the collection and tabulation of data for reporting purposes and maintains files of confidential information submitted for review. * Assures that activities and processes are compliant with CMS, National Committee of Quality Assurance (NCQA) guidelines, and Molina policies and procedures. * Participates in the daily workload of the department, performing Representative duties as needed. * Facilitates interviews with pharmacy service representative job applicants, and provides hiring recommendations to leadership. * Provides coaching for pharmacy representatives, and helps identify and provide for training needs in collaboration with pharmacy leadership. * Communicates effectively with practitioners and pharmacists. * Collaborates with and keeps pharmacy leadership apprised of operational issues, including staffing resources, program and system needs. * Assists with development of and maintenance of pharmacy policies and procedures * Participates in the development of programs designed to enhance preferential or required targeted drugs or supplies. Required Qualifications * At least 5 years of experience in health care, preferably within a health-related call center environment, or equivalent combination of relevant education and experience. * Knowledge of prescription drug products, dosage forms and usage. * Experience designing, implementing, monitoring, and evaluating metrics that measure call center agent productivity. * Working knowledge of medical/pharmacy terminology * Excellent verbal and written communication skills. * Microsoft Office suite, and applicable software program(s) proficiency. Preferred Qualifications * Supervisory/leadership experience. * Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. * Call center experience. * Managed care experience. 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 Pay Range: $55,706.51 - $80,464.96 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

The Strategy Advancement Director is responsible for advancing Molina's growth strategy and positioning the company for success in Medicaid, CHIP, DSNP, and Marketplace procurements. Reporting to the Vice President, Business Development, this position plays a pivotal role in the pre-RFP and procurement phases, guiding and organizing the project, ensuring deliverables are met, conducting research, tracking Business Development and/or Health Plan steps and projects, owning the governance structure for every opportunity, pulling together all the supporting team activities and pieces and connecting the dots between winning strategy and the relationships and partnerships developed by the VP, Business Development. This role requires a deep understanding of Medicaid programs, the regulatory environment, and the unique challenges of populations (i.e. TANF, ABD, DSNP, Foster Care, and DD/IDD). The Strategy Advancement Director works collaboratively across departments, including Product Development, Business Development, and Health Plans, to ensure that strategic initiatives align with state-specific priorities and are positioned for success in competitive procurements. The Director partners with the VP Market Development to provide thought leadership and subject matter expertise, identifying trends, providing insights, and continuously innovating to strengthen Molina's market position. Job Duties * Strategy Development & Innovation * Collaborate on the development of state-specific strategies aligned with state priorities, procurement objectives, and evolving Medicaid needs. Translate state regulatory requirements into actionable go-to-market strategies that are innovative and differentiate Molina in competitive procurements * Collaborate with Product Development, Health Plan leaders, Growth Leaders and cross-functional teams to support integration of innovative care models, operational efficiencies, and value-based care solutions tailored to the unique needs of market specific Medicaid populations, especially high-risk or vulnerable groups such as dual-eligible members, foster care, and ABD * Conduct market research, analyze industry trends, and monitor competitor activities to identify innovation opportunities. Propose solutions that address Medicaid ecosystem pain points and enhance Molina's value proposition * Use insights from market research and competitive analysis to stay informed on state Medicaid trends, regulatory changes, and market conditions, and to guide strategic adjustments and future market positioning * Drive the development of win themes and strategy recommendations that align with state priorities, competitive dynamics, and the latest Medicaid trends, positioning Molina as a leader in Medicaid managed care * Track regulatory compliance and address any operational concerns or state-specific issues identified during the pre-procurement phase. Escalate issues when necessary and work to resolve them proactively * Market Development and Strategy Execution * Collaborate on the development of pre-RFP strategy and market readiness, creating and tracking playbooks, plans, and deliverables for Molina's strategy two to three years before RFP release. Ensure alignment with organizational goals and state requirements by collaborating with Market VPs, AVPs, and stakeholders * Identify and engage in thought leadership opportunities by representing Molina at state and national Medicaid conferences, industry forums, and other key events that enhance Molina's brand and expertise in Medicaid care delivery * Stakeholder Engagement & Thought Leadership * Support and track the development of relationships with state agencies, legislative leaders, regulatory bodies, and community organizations to enhance Molina's reputation and strengthen partnerships that could influence procurement outcomes * Represent Molina in strategic discussions with external partners and internal leadership, ensuring clear communication of strategy, innovation, and value propositions * Collaborate with internal stakeholders to influence thought leadership materials and content that showcase Molina's innovative approaches to Medicaid, particularly in high-needs areas like DSNP, ABD, and complex populations * Proposal Support & Competitive Differentiation * Serve as an expert on the pre-procurement process for the proposal team and closely collaborate with the Proposal Director to ensure consistency between market strategy, capture strategy and proposal content. Collaborate with the Proposal Director to ensure consistency between market strategy and RFP content * Track and support the execution of win strategy and strategic recommendations being incorporated throughout the proposal, ensuring Molina's proposals are differentiated and align with state-specific priorities and the competitive landscape * Actively participate in blue, pink, and red team reviews, providing strategic feedback to ensure proposal materials effectively communicate Molina's competitive advantages and compliance with RFP requirements * Support orals preparation, working across matrix partners to refine materials and messaging for presentations to state agencies * Operational Excellence & Cross-Functional Coordination * Use tools (i.e. Salesforce) to document market intelligence, track engagement activities, and share insights across departments. Ensure that data-driven insights are leveraged in proposal content development and strategic planning * Collaborate with the Growth Strategy, Competitive Intelligence and other stakeholders to leverage the competitive intelligence repository that informs decision-making and provides a strategic edge in Medicaid procurements * Develop project plans and roadmaps to guide the timely execution of pre-RFP and procurement activities, ensuring effective collaboration and alignment across functional teams * Facilitate cross-functional coordination for market entry, retention, and development strategies, ensuring that all teams are aligned and executing efficiently * Supports the VP Business Development as a SME during the "warranty period" post award through implementation to the IMO and health plan leadership * Mentorship & Team Development * Mentor junior staff and interns within the Business Development teams, fostering skills in strategic thinking, market research, and pre-procurement planning * Participate in business development activities on an ad-hoc basis, contributing to team knowledge and providing strategic insights to senior leadership * 50% or more Travel required Job Qualifications REQUIRED QUALIFICATIONS: * Bachelor's degree in business, Public Policy, Healthcare Administration or a related field or equivalent combination of education and experience * 7 years in market strategy, business development, or healthcare consulting, specifically within Medicaid managed care or equivalent related field * Proven experience in pre-RFP strategy development, with a strong understanding of Medicaid programs, including TANF, ABD, DSNP, and CHIP populations * Demonstrated ability to drive innovative solutions in the Medicaid space, leveraging market research and industry trends to inform strategic decisions * Experience with Salesforce or similar tools to track market insights, engagement activities, and manage data * Strong experience in stakeholder engagement, particularly with state Medicaid agencies, regulatory bodies, and community-based organizations * Advanced proficiency in Microsoft Office tools (Excel, PowerPoint, Word), including for strategy development, data analysis, and presentation creation PREFERRED QUALIFICATIONS: * Master's degree (MBA, MPH, MPA) in business, public policy, or healthcare administration * 7+ years in business development and Medicaid procurements, particularly with complex populations (e.g., DD/IDD, Foster Care, Dual-Eligible Members) * Experience with Salesforce or similar tools to track market insights, engagement activities, and manage data * Conference management experience and participation in industry forums 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: $107,028 - $208,705 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Provides senior level audit support for delegation oversight activities. Responsible for ensuring delegates are complaint with the applicable state, federal, contractual requirements, National Committee for Quality Assurance (NCQA), and Molina requirements for the health plan(s) they support. Identifies risk and non-compliance, issues corrective action, and actively manages the corrective action process to completion reducing and managing Molina's risk. Essential Job Duties * Leads and performs pre-delegation, annual audits, and ensures all components of audit activities comply with contractual, regulatory, and accreditation requirements. * Conducts detailed and focused audits on delegates' policies, procedures, case files and evidence of ongoing monitoring to ensure quality and cost-effective provision of delegated services. * Engages delegate leadership to educate, collaborate, and/or remediate risks to Molina. * Leverages highly skilled analytical insights and experience to identify delegate systemic issues and risks that impact the business; collaborates with health plans and/or corporate departments and other business owners to actively address and mitigate risk to Molina. * Conducts analysis of audit issues to identify root-causes, develops and issues corrective action plans (CAPs), and documents follow-up to ensure successful remediation. * Prepares, tracks and provides audit finding reports in accordance with departmental requirements. * Prepares, submits and presents audit reports to delegation oversight committees. * Presents audit findings to delegates, and makes recommendations for improvements based on audit results. * Collaborates with delegation oversight leadership to develop and maintain assessment tools. * Makes independent decisions on complex issues and project components. * Serves as subject matter expert on policies, regulations, contractual requirements and delegate contracts for the relevant area. * Remains current on applicable regulatory, contractual and accreditation requirements and standards; interprets regulatory, contractual and accreditation changes and assesses their impact on the relevant area. * Conducts outreach to multiple department heads regarding key performance indicator (KPI) data analysis for quarterly meetings. * Provides training and support to new and existing delegation oversight team members. Required Qualifications * At least 3 years of managed care experience, including at least 2 years of delegation oversight auditing experience, or equivalent combination of relevant education and experience. experience. * Ability to work independently or in a team, support multiple projects at once, and perform other duties or special projects as required. * Ability to collaborate cross-functionally across a highly matrixed organization. * Strong attention to detail and organizational skills. * Strong critical-thinking, and problem-solving/analytical abilities. * Strong interpersonal and verbal/written communication skills. * Microsoft Office suite proficiency (including Excel), and ability to learn/navigate new software programs. Preferred Qualifications * Certified Credentialing Specialist (CCS), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN), Certified Clinical Coder (CCD), Certified Medical Audit Specialists (CMAS), Certified Professional in Healthcare Management (CPHM) and/or other health care certification/licensure. If licensed, license must be active and unrestricted in state of practice. 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 Pay Range: $80,168 - $128,519 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Provides support for pharmacy technician activities. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Shift: (11 AM-7:30 PM MST or 12:30-9 PM MST) Essential Job Duties * Performs initial receipt and review of non-formulary or prior authorization requests against pharmacy plan approved criteria; requests additional information from providers as needed to properly evaluate requests. * Accurately enters approvals or denials of requests. * Facilitates prior authorization requests within established pharmacy policies and procedures. * Participates in the development/administration of pharmacy programs designed to enhance the utilization of targeted drugs and identification of cost-saving pharmacy practices. * Identifies and reports pharmacy departmental operational issues and resource needs to appropriate leadership. * Assists Molina member services, pharmacies, and health plan providers in resolving member prescription claims, prior authorizations, and pharmacy service access issues. * Articulates pharmacy management policies and procedures to pharmacy/health plan providers, Molina staff and others as needed. Required Qualifications * At least 2 years pharmacy technician experience, or equivalent combination of relevant education and experience. * Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. * Ability to abide by Molina policies. * Ability to maintain attendance to support required quality and quantity of work. * Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA). * Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers. * Excellent verbal and written communication skills. * Microsoft Office suite (including Excel), and applicable software program(s) proficiency. 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 Pay Range: $21.65 - $31.71 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Provides lead level analyst support for configuration information management activities. Responsible for accurate and timely implementation and maintenance of critical information on claims databases, synchronizing operational and claims systems data and application of business rules as they apply to each database, validating data to be housed on databases, and ensuing adherence to business and system requirements of customers as it pertains to contracting, benefits, prior authorizations, fee schedules, and other business requirements. Essential Job Duties * Analyzes and interprets data to determine appropriate configuration changes. * Accurately interprets specific state and/or federal benefits, in addition to other business requirements, and converts terms to configuration parameters. * Manages coding, updating and maintaining benefit plans, provider contracts, fee schedules and various system tables in the user interface. * Applies experience and knowledge to research and resolve claim/encounter issues and pended claims, and updates system(s) as necessary. * Loads and maintains contracts, benefit and/or reference table information into the claims payment system and other applicable systems. * Participates in defect resolution for assigned component(s). * Participates in the implementation and conversion of new and existing health plans. * Assists in planning and coordination of application upgrades and releases, including development and execution of some test plans. * Assists with development of configuration standards and best practices, and suggests improvement processes to ensure systems are working efficiently and enhance quality. * Creates reporting tools to enhance communication on configuration updates and initiatives. * Negotiates expected configuration information management completion dates with health plans. * Collaborates with internal and external stakeholders to understand business objectives and processes. * Solutions with health plans and corporate functions to ensure all end-to-end business requirements have been documented. * Assists leadership in establishing standards, guidelines, and best practices for the configuration information management team. * Represents as a departmental configuration information management subject matter expert. * Supports various department-wide configuration information management projects. * Provides training and support to new and existing configuration information management team members, including configuration functionality, enhancements and updates * Manages fluctuating volumes of work, and prioritizes work to meet deadlines and needs of the configuration department and user community. Required Qualifications * At least 5 years of configuration information management experience maintaining databases, and/or analyst experience within a health care operations setting in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience. * Must have Contract configuration experience in Networx. * Experience with QNXT is preferred. * Advanced experience using a claims processing system. * Advanced experienced verifying documentation related to updates/changes within a claims processing system. * Advanced experience validating and confirming information related to provider contracting, network management, credentialing, benefits, prior authorizations, fee schedules, and other business requirements. * Analytical and critical-thinking skills. * Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery * High attention to detail. * Effective verbal and written communication skills. * Microsoft Office suite proficiency, including intermediate to advanced Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency. 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 Pay Range: $80,168 - $155,508 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Molina's Provider Contracting function provides guidance, signature support services, standards and resources to help Molina Healthcare successfully establish and maintain distinct high performing networks of compassionate and culturally sensitive providers who: * Are aligned with our mission to provide quality health services to financially vulnerable families and individuals covered by government programs; * Help meet or exceed applicable access criteria and adequacy standards for covered services; * Agree to sign standard provider services agreements approved by applicable state/federal agencies and built on Molina's business standards that include sustainable value-based reimbursements; and * Are committed to providing quality healthcare for low income Members in an efficient and caring manner.' Knowledge/Skills/Abilities * Under the leadership of the AVP, Provider Network Management & Operations, oversees development and implementation of provider network and contract strategies, identifying those specialties and geographic locations upon which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of Molina membership. * Develops and maintains a standard provider reimbursement strategy consistent with reimbursement tolerance parameters (across multiple specialties/geographies). Obtains input from Corporate, Legal and other stakeholders regarding new reimbursement models and oversees their development. * Develops and maintains a system to track contract negotiation activity on an ongoing basis throughout the year; utilizes and oversees departmental training on the enterprise contract management system (Emptoris). * Directs the preparation of provider contracts and oversees negotiation of contracts in concert with established company templates and guidelines with physicians, hospitals, and other health care providers. * Contributes as a key member of the department's leadership team and participates in committees addressing the department's strategic goals and organization. * Oversees the maintenance of all provider contract information and provider contract templates and ensures that contracts can be configured within the QNXT system. Works with Legal, Corporate and other stakeholders as needed to modify contract templates to ensure compliance with all contractual and/or regulatory requirements. * Monitors and reports network adequacy for Medicare and Medicaid services. * Develops strategies to improve EDI/MASS rates. * Educates and works with assigned state Health Plans on any corporate changes or initiatives as necessary. * Works with assigned national vendors to improve contractual terms and maintain positive relationships. * Provides national contracts support for other Molina departments/functions, including: Provider Services (and activities with provider association(s) and Joint Operating Committee management); Delegation Oversight; Provider Network Administration (provider information management and business analyses of national contracts/benefits to support accurate configuration for claims payment); Provider/Member Inquiry Research and Resolution; and Provider/Member Appeals and Grievances. * Coordinates with Corporate and Business Development teams to ensure that Molina grows faster (profitable growth) than our competitors in target new markets and expansion opportunities. * Provides training and guidance as needed to the Contract Managers and Contract Specialist(s). * Helps develop and utilize standardized contract templates and Pay for Performance strategies. * Utilizes sound reporting and analytical tools to develop and refine strategic work plans.. Job Qualifications Required Education Bachelor's Degree in a related field (Business Administration, etc.) or equivalent experience. Required Experience 7 - 10 years minimum experience in Healthcare Administration, Managed Care, and/or Provider Network Mgmt & Operations with an emphasis on value based provider contracting. Required License, Certification, Association N/A Preferred Education Master's Degree Preferred Experience 3-5 years minimum experience in contracting with hospitals, physician groups, high volume specialists and ancillary providers. Preferred License, Certification, Association N/A 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: $107,028 - $250,446 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Designs and implements processes and solutions associated with a wide variety of data sets used for data/text mining, analysis, modeling, and predicting to enable informed business decisions. Gains insight into key business problems and deliverables by applying statistical analysis techniques to examine structured and unstructured data from multiple disparate sources. Collaborates across departments and with customers to define requirements and understand business problems. Uses advanced Excel, SQL querying, and reporting methods to develop solutions. Job Duties * Extracts and compiles information from large data sets from various systems to identify and analyze outliers. * Provide quantitative and qualitative data analysis in the reporting of patterns, insights, and trends to decision-makers. * Works with internal, external and enterprise clients as needed to research, develop, and document new standard reports or processes. * Implements and uses analytics software and systems to support department goals. * Tracks trends related to various feeds, with focus on membership, revenue, and commissions. * Identify any deficiencies within the process, strategize and design improvements where possible. Job Qualifications REQUIRED EDUCATION: Associate's degree or equivalent combination of education and experience REQUIRED EXPERIENCE: * 1-3 years related experience * Proficiency in MS SQL queries and database development. * Proficient in MS Office Suite products, key skills in Excel (VLOOKUPs and pivots). * Intermediate proficiency with complex SQL queries, and stored procedures. * Strong critical thinking and attention to detail. * Ability to effectively communicate with technical and non-technical stakeholders. * Strong time management skills to manage simultaneous projects and tasks to meet internal deadlines PREFERRED EDUCATION: Bachelor's degree or equivalent combination of education and experience PREFERRED EXPERIENCE: 2 - 4 years related experience 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: $80,168 - $128,519 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Provides senior level support for accurate and timely intake and interpretation of regulatory and/or functional requirements related to but not limited to coverage, reimbursement, and processing functions to support systems solutions development and maintenance. This role includes coordination with stakeholders and subject matter experts on partnering teams and supporting governance committees where applicable. JOB DUTIES * Develops and maintains requirement documents related to coverage, reimbursement and other applicable system changes in areas to ensure alignment to regulatory baseline requirements and any health plan/product team developed requirements. * Monitors regulatory sources to ensure all updates are aligned as well as work with operational leaders within the business to provide recommendations for process improvements and opportunities for cost savings. * Leads coordinated development and ongoing management /interpretation review process, committee structure and timing with key partner organizations. Interpret customer business needs and translate them into application and operational requirements. * Communicates requirement interpretations and changes to health plans/product team and various impacted corporate core functional areas for requirement interpretation alignment and approvals as well as solution traceability through regular meetings and other operational process best practices. * Where applicable, codifies the requirements for system configuration alignment and interpretation. * Provides support for requirement interpretation inconsistencies and complaints. * Assists with the development of requirement solution standards and best practices while suggesting improvement processes to consistently apply requirements across states and products where possible. * Self-organized reporting to ensure health plans/product team and other leadership are aware of work efforts and impact for any prospective or retrospective requirement changes that can impact financials. * Coordinates with relevant teams for analysis, impact and implementation of changes that impact the product. * Engages with operations leadership and Plan Support functions to review compliance-based issues for benefit planning purposes. Recoveries & Disputes * Review and validate provider complaints and payment disputes, ensuring accurate and timely resolution in line with policy and contractual guidelines. * Partner with provider relations, Health plans and appeals teams to address recurring dispute trends and recommend systemic solutions. * Evaluate root cause for the disputes and recommend improvements to reduce claim errors and prevent improper payments. * Provide actionable insights and recommendations to leadership to drive continuous improvement. Skills & Competencies * Proven experience handling provider disputes, appeals, and overpayment recoveries in a managed care or payer environment. * In-depth knowledge of medical and hospital claims processing, including CPT/HCPCS, ICD, and modifier usage. * Strong understanding of claim system configurations, payment policies, and audit processes. * Exceptional analytical, problem-solving, and documentation skills. * Ability to translate complex business problems into clear system requirements and process improvements. * Proficiency in Excel * Knowledge in QNXT preferred * Strong communication and stakeholder management skills with ability to influence across teams. KNOWLEDGE/SKILLS/ABILITIES * Maintains relationships with Health Plans/Product Team and Corporate Operations to ensure all end-to-end business requirements have been documented and interpretation are agreed on and clear for solutioning. * Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas. * Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company. * Ability to concisely synthesize large and complex requirements. * Ability to organize and maintain regulatory data including real-time policy changes. * Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems. * Ability to work independently in a remote environment. * Ability to work with those in other time zones than your own. JOB QUALIFICATIONS Required Qualifications * At least 4 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 * Familiarity with administration systems * Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams * Previous success in a dynamic and autonomous work environment Preferred Qualifications * Project implementation experience * Knowledge and experience with federal regulatory policy resources including Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA). * Medical Coding certification. 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. Pay Range: $80,168 - $128,519 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Our client located in Espanola, New Mexico has a need for a Nurse to join their team for a Travel assignment. What MedicalPeople looks for in ICU Nurses to join our Critical Care Nursing Team: Critical Thinkers who have demonstrated accurate assessment skills to determine patients health status. Ability to provide quality care to critical condition patients who require constant monitoring and due to their life-threatening conditions. 2 Years of Nursing experience in critical care Nursing positions Active state license as a Registered Nurse. Current BLS, ACLS and PALS (facility dependent). Strong documentation skills. Ability to learn and adjust new EMR systems, equipment, and facilities. Strong communication skills and ability to work as a team member in a multidisciplinary team. Willingness to float and assist others in the delivery of patient care.