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Sr. Specialist, Delegation Oversight/Claims Auditor

Company: Molina Healthcare
Location: Long Beach
Posted on: June 12, 2021

Job Description:

JOB FUNCTION:

Responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with DMHC and DHCS requirements including delegation standards and requirements contained in the Molina Medical Compliance and Fraud, Waste and Abuse Program. Claims Audit experience is highly desirable.

KNOWLEDGE, SKILLS & ABILITIES (Generally, the occupational knowledge and specific technical and professional skills and abilities required to perform the essential duties of this job):

  • Coordinates, conducts, and documents delegation assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
  • Prepares status reports from Delegated Entities. Develops corrective action plans when deficiencies are identified, and documents follow-up to completion. Ensures compliance with reporting requirements by tracking the receipt and completeness of reports.
  • Develops corrective action plans when compliance issues are identified, and document follow-up to completion.
  • Assists with meetings of the Delegation Oversight Committee, including the preparation of documents for committee oversight of delegated functions.
  • Works with Network Management team to develop and maintain delegation agreements and assessment tools.
  • Prepares delegation oversight document evidence for state monitoring visits and NCQA accreditation surveys and participates on Molina's work team.

REQUIRED EDUCATION:

Bachelor's Degree or equivalent combination of education and experience.

REQUIRED EXPERIENCE:

  • 3+ years managed care experience.
  • Min. 1 year experience completing delegation oversight assessment/ audits.
  • Data analysis experience.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

Valid State Driver's License

PREFERRED EDUCATION:

Bachelor's Degree in Business or Health Care related field.

PREFERRED EXPERIENCE:

  • 5 years managed care experience.
  • 2 years experience completing delegation oversight assessments/audits.
  • Quality management/regulatory experience with increasing responsibility.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

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.

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.

Keywords: Molina Healthcare, Long Beach , Sr. Specialist, Delegation Oversight/Claims Auditor, Other , Long Beach, California

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