Qureos Mentor

Molina Healthcare

<div>JOB DESCRIPTION

Job Summary

Provides senior level analyst support for Molina enterprise risk and quality reporting activities. Designs and develops reporting solutions to support Healthcare Effectiveness Data and Information Set (HEDIS) auditing, rate tracking, identification of targeted interventions, and performance metric outcome tracking. Collects, validates, analyzes, and organizes data into meaningful reports for operational/strategic analysis and decision-making. 


Essential Job Duties
<ul><li>Collaborates cross-functionally with internal departments across the enterprise to capture and document quality-related reporting requirements; builds reporting solutions, and educates users on how to use reports.</li><li>Assists quality data analytics leaders in predictive intervention strategic analytics, and corresponding tracking of progress and impact of interventions.</li><li>Assists with retrospective HEDIS rate tracking and supplemental data impact reporting.</li><li>Develops medical record review project reporting to track progress and team productivity reporting.</li><li>Develops quality assurance (QA) reporting and automated analytical reporting modules for the Medicaid, Marketplace and Medicare/Medicare-Medicaid Plan (MMP) lines of business.</li><li>Analyzes and reports managed care data including claims, pharmacy, lab and HEDIS rates.</li><li>Assists quality department with HEDIS measure deep dives to support HEDIS audit and revenue at risk reporting.</li><li>Calculates and tracks HEDIS rates for all intervention outcomes for all markets and lines of business.</li><li>Works in an agile business environment to derive meaningful information out of complex/large data sets through data analysis, data mining, verification, scrubbing, and root-cause analysis.</li><li>Conducts root-cause analysis for business data issues.</li><li>Analyzes data sets and trends for anomalies, outliers, trend changes and opportunities using statistical tools and techniques to determine significance and relevance; utilizes extrapolation, interpolation, and other statistical methodologies to predict future trends in cost, utilization, and performance.</li><li>Assists 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.</li><li>Tracks, facilitates and manages changes in the data warehouse platform and performs transparent upgrades to analytic reporting modules to ensure no impact to end-users.</li><li>Conducts 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.</li><li>Represents as a HEDIS subject matter expert; supports health plans improve on underperforming quality measures.</li><li>Completes special quality data-related projects as assigned.</li><li>Provides training and support to new and existing data analytics/reporting team members.</li></ul> 
<div>Required Qualifications 
<ul><li>At least 4 years of experience mapping, scrubbing, scrapping, and cleaning data, and analysis experience related to HEDIS and/or risk adjustment, including experience working with relational databases, Microsoft Transact-SQL (T-SQL), SQL Server Integration Services (SSIS), SQL Server Reporting Services (SSRS), and Power BI, and at least 2 years of experience in a managed care organization, in addition to predictive modeling experience in health care quality and HEDIS rate tracking, medical record review tracking, interventions tracking, and statistical analysis/HEDIS forecasting experience supporting quality, finance, and health plan functions, or equivalent combination of relevant education and experience.</li><li>Analytical mindset, excellent attention to detail, and problem-solving skills.</li><li>Experience in working with complex data to include quantifying, measuring, and analyzing financial/performance management and utilization metrics.</li><li>Experience working with Microsoft T-SQL, Databricks SQL and Power BI.</li><li>Experience writing complex SQL queries, functions, procedures and data design.</li><li>Experience with Microsoft Azure, Amazon Web Services (AWS), or Hadoop.</li><li>Ability to manage multiple priorities in a fast-paced, deadline-driven environment.</li><li>Strong business acumen with the ability to connect data insights to strategic goals.</li><li>Ability to communicate complex analytical results clearly to non-technical audiences.</li><li>Self-starter with a continuous improvement mindset.</li><li>Effective verbal and written communication skills.</li><li>Microsoft Office suite proficiency.</li></ul></div> 


Preferred Qualifications
<ul><li>Familiarity with data science techniques and languages like Python and R programming.</li></ul> 
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</div>

Senior Analyst, National Quality Analytics & Performance (Remote)

<div>JOB DESCRIPTION Job Summary

Must reside in Florida.

Provides support for claims examination activities including evaluation of adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors. 


Essential Job Duties
<ul><li>Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.</li><li>Manages a caseload of claims - procures all medical records and statements that support the claim.</li><li>Makes recommendations for further investigation and/or resolution of claims.</li><li>Reduces defects through proactive identification of error issues as it relates to pre-payment of claims through adjudication/trend identification, and recommends solutions to resolve issues.</li><li>Meets claims department quality and production standards.</li><li>Supports claims department initiatives to improve overall claims function efficiency.</li><li>Completes basic claims projects as assigned.</li></ul> 
Required Qualifications
<ul><li>At least 1 year of experience in a clerical role in a claims, and/or customer service setting - preferably in managed care, or equivalent combination of relevant education and experience.</li><li>Data entry and research skills.</li><li>Organizational skills and attention to detail.</li><li>Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.</li><li>Customer service experience.</li><li>Effective verbal and written communication skills.</li><li>Microsoft Office suite and applicable software programs proficiency.</li></ul> 
Preferred Qualifications
<ul><li>Health care claims/billing experience.</li></ul> 
#PJClaims2

#LI-AC1 


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</div>

Examiner, Claims

<div>Job Summary

Provides non-clinical administrative support to the care management function, and contributes to interdisciplinary team efforts supporting provision of integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. 
 
Essential Job Duties
<ul><li>Facilitates administrative support including case assignment, member screening and scheduling, correspondence processing, data entry and telephone and clerical support for team facilitating care management related services for members.</li><li>Facilitates initial review of assigned case levels and assists in case management assignment to care managers.</li><li>Reviews data to identify principle member needs and works under the direction of the care manager to implement care plan.</li><li>Schedules member visits with care managers as needed.</li><li>Screens members according to Molina policies and processes and assists care management staff during process of identifying appropriate member services.</li><li>Coordinates required member services in accordance with member benefit plan.</li><li>Promotes communication both internally and externally to enhance effectiveness of care management services.</li><li>Processes member and provider correspondence.</li></ul> 

Required Qualifications
<ul><li>At least 1 year of experience in an administrative support role in health care, or equivalent combination of relevant education and experience.</li><li>Strong attention to detail.</li><li>Problem-solving skills.</li></ul>
&bull; Working knowledge of Microsoft Office (Outlook, Word, Excel) or other comparable software. &bull; Excellent customer service skills. &bull; Time-management and organizational skills. 
<ul><li>Strong verbal and written communication skills.</li><li>Microsoft Office suite/applicable software program(s) proficiency.</li></ul> 

Preferred Qualifications
<ul><li>Certified Medical Assistant (CMA).</li></ul> 
 
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</div>

Care Management Processor

<div>JOB DESCRIPTION Job Summary

Do you want a career where you build lasting relationships with the people you partner with? Do you want to make a difference in the lives of people with long-term health care needs? Then TMG wants to hear from you! 

We&rsquo;re currently looking for someone with a social services or human services background to join our team. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS Program and the TMG IRIS Consultant Agency. While your office will be home-based, you will have regularly scheduled visits with IRIS participants in their home and community. 


As an IRIS Consultant (IC), you will build relationships with the people you partner with and help them navigate and get the most out of the Wisconsin IRIS program &ndash; a Medicaid long-term care option for older adults and people with disabilities. You can learn more about the IRIS program on the Wisconsin Department of Health Services website here. Together, you will identify the long-term care goals of the people enrolled in IRIS, and find creative ways to achieve those goals. 


ICs play an important role in helping people of various backgrounds and abilities live the lives that they choose. In fact, people constantly tell us how supportive our ICs are and what a positive impact our ICs have had on their lives! Successful candidates for this position will be compassionate, genuine, resourceful partners with an eye for high quality work, and who are excited to work side-by side with people enrolled in IRIS. 


As an IC, you will connect people to the resources available in their community. You will also help them develop customized IRIS plans for achieving their goals related to employment, housing, health, safety, community membership, transportation, and lasting relationships. While you will have a routine for the work that you do, no two days are alike! 


TMG wants to find the best possible candidates, so we created this Realistic Job Preview to provide you with an inside look at the position and our organization. Find out more about the IRIS Consultant position by clicking on the link and then reviewing the job posting below. 


TMG is committed to maintaining a diverse and inclusive workforce and prioritizes helping staff have a good work/life balance. Even though the position is remote, you&rsquo;ll have lots of support from your TMG team and coworkers across the organization. If this sounds like the job for you, apply today! 


KNOWLEDGE/SKILLS/ABILITIES 

<ul>
<li>Required to meet in person with the IRIS participant a minimum of four times per year, with one required annual visit in the home of the participant. Because IRIS is a self-directed program, it is important for ICs to be available upon the request of the participant.</li>
<li>Responsible for providing program orientation to new participants. During this time, participants will learn their rights and responsibilities as someone enrolled in the IRIS program, including verifying legal documents, completing employee paperwork and the responsible use of public dollars.</li>
<li>Explore a broad view of the participant's life, including goals, important relationships, connections with the local community, interest in employment, awareness of the Self-Directed Personal Care option, and back-up support plans.</li>
<li>Assist participants in identifying personal outcomes and ensure those outcomes are being met on an ongoing basis, all while staying within the participant's IRIS budget and within the requirements of the IRIS program determined by the Department of Health Services (DHS).</li>
<li>Responsible for documenting all orientation and planning activities within the IRIS data system (WISITs) within 48 business hours of the visit with the participant.</li>
<li>Research community resources and natural supports that will fit the individual outcomes for each participant and share that information with them as it becomes available.</li>
<li>Responsible for documenting progress and changes as needed within the plan and the data system anytime a modification is requested by a participant.</li>
<li>Budget Amendment or One-Time Expense paperwork may be required depending upon factors associated with the participant and their individual IRIS budget.</li>
<li>Educate participants on how to read and interpret their monthly budget reports to ensure that participants operate within their budget. Being a liaison between the Fiscal Employer Agency and the IRIS Consultant Agency is also a large part of the position, which includes assisting participants with provider billing, seeking support brokers, tracking receipts, ensuring their workers are paid and mitigating areas of potential risk or conflicts of interest.</li>
<li>Responsible to develop engaged and trusting relationships with participants and communicate program changes and compliance effectively.</li>
<li>Responsible to maintain confidentiality and HIPPA compliance.</li>
<li>Work collaboratively with other IRIS Consultant Agency staff in order to ensure a successful implementation of participants' plans.</li>
<li>Attend in-person monthly team meetings with other ICs and their supervisor. In addition, weekly IC and IRIS Consultant Supervisor phone check-ins may occur, along with other duties as assigned.</li>
</ul>
Required Qualifications<div> 
<ul><li>At least 2 years experience in health care, preferably in care coordination, and at least 1 year of experience serving target groups of the IRIS program (adults with intellectual/physical disabilities or older adults), or equivalent combination of relevant education and experience.</li><li>Bachelor&rsquo;s degree in a social work, psychology, human services, counseling, nursing, special education, or a closely related field (or four years of commensurate experience if no degree).</li><li>Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements unless otherwise required by law.</li><li>Ability to develop positive and effective work relationships with coworkers, clients, participants, providers, regulatory agencies and vendors.</li><li>Ability to work independently with minimal supervision and demonstrate self-motivation.</li><li>Demonstrated knowledge of long-term care programs.</li><li>Familiarity with principles of self-determination.</li><li>Problem-solving and critical-thinking skills.</li><li>Excellent time-management and prioritization skills.</li><li>Ability to focus on multiple projects simultaneously and adapt to change.</li><li>Ability to develop and maintain professional relationships and work through challenging situations.</li><li>Comfortable working within a variety of settings with ability to adjust style as needed to work with diverse populations, various personalities, and personal situations.</li><li>Demonstrated knowledge of community resources.</li><li>Proactive and detail-oriented.</li><li>Excellent verbal and written communication skills.</li><li>Microsoft Office suite/applicable software program(s) proficiency.</li></ul> 
</div> 
 
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</div>

Specialist, IRIS Consulting (Milwaukee County, WI)

<div>JOB DESCRIPTION

Job Summary

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
<ul>
<li>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.</li>
<li>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.</li>
<li>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.</li>
<li>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.</li>
<li>Where applicable, codifies the requirements for system configuration alignment and interpretation.</li>
<li>Provides support for requirement interpretation inconsistencies and complaints.</li>
<li>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.</li>
<li>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.</li>
<li>Coordinates with relevant teams for analysis, impact and implementation of changes that impact the product.</li>
<li>Engages with operations leadership and Plan Support functions to review compliance-based issues for benefit planning purposes.</li>
</ul>
KNOWLEDGE/SKILLS/ABILITIES
<ul>
<li>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.</li>
<li>Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas.</li>
<li>Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company.</li>
<li>Ability to concisely synthesize large and complex requirements.</li>
<li>Ability to organize and maintain regulatory data including real-time policy changes.</li>
<li>Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems.</li>
<li>Ability to work independently in a remote environment.</li>
<li>Ability to work with those in other time zones than your own.</li>
</ul>
JOB QUALIFICATIONS

Required Qualifications
<ul>
<li>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.</li>
<li>Policy/government legislative review knowledge</li>
<li>Strong analytical and problem-solving skills</li>
<li>Familiarity with administration systems</li>
<li>Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams</li>
<li>Previous success in a dynamic and autonomous work environment</li>
</ul>
Preferred Qualifications
<ul>
<li>Project implementation experience</li>
<li>Knowledge and experience with federal regulatory policy resources including Centers for Medicare &amp; Medicaid Services (CMS) and the Affordable Care Act (ACA).</li>
<li>Medical Coding certification.</li></ul> 


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.</div>

Senior Business Analyst

Mon - Fri Hours: <ul><li>9am -5:30pm PST</li><li>10am -6:30pm MST</li><li>11am -7:30pm CST</li><li>12pm -8:30pm EST</li></ul>JOB DESCRIPTION Job SummaryProvides support for pharmacy Medication Therapy Management (MTM) activities. Contributes to overarching pharmacy strategy to ensure member access to medically necessary prescription drugs, optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties <ul><li>Collaborates with pharmacists on medication adherence and provides follow-up on identified adherence barriers.</li><li>Performs outreach to members, prescribers and/or pharmacies as needed.</li><li>Participates in the development/administration of pharmacy programs designed to enhance the utilization of targeted drugs and identification of cost-saving pharmacy practices.</li><li>Identifies and reports pharmacy operational issues and resource needs to appropriate leadership.</li><li>Assists Molina member services, pharmacies, and health plan providers in resolution of member prescription claim, prior authorization, and pharmacy service access issues.</li><li>Articulates pharmacy management policies and procedures to pharmacy/health plan providers, Molina staff and others as needed.</li></ul>Required Qualifications <ul><li>At least 2 years pharmacy technician experience, preferably supporting Medication Therapy Management (MTM), or equivalent combination of relevant education and experience.</li><li>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.</li><li>Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.</li><li>Ability to abide by Molina policies.</li><li>Ability to maintain attendance to support required quality and quantity of work.</li><li>Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA).</li><li>Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.</li><li>Excellent verbal and written communication skills.</li><li>Microsoft Office suite (including Excel), and applicable software program(s) proficiency.</li></ul>Preferred Qualifications <ul><li>Medication Therapy Management (MTM) experience.</li></ul>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: $12.19 - $26.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Remote -Pharmacy Technician, Clinical/Medication Therapy Mgmt

<div>
 
 JOB DESCRIPTION Job Summary
 
 
 
 Must reside in Florida.
 
 
 Provides level I support center customer service excellence to meet the needs of Molina members and providers. Resolves issues and addresses needs fairly and effectively, while demonstrating Molina values. Provides product and service information, and identifies opportunities to improve the member and provider experience.
 
 
 
 Essential Job Duties
 
 
 
 <ul>
 <li>
 Provides service support to members and/or providers using one or more support center communication channels serving multiple states and/or products including but not limited to: phone, chat and email, in addition to other administrative off phone duties supporting Medicaid, Medicare and/or Marketplace lines of business.
 </li>
 <li>
 Conducts various surveys related to health assessments and member/provider satisfaction.
 </li>
 <li>
 Accurately documents pertinent details related to member or provider inquiries.
 </li>
 <li>
 Works regularly scheduled shifts within Molina hours of operation, follows protocol related to scheduled lunches and breaks, and accommodates overtime and/or weekends as needed.
 </li>
 <li>
 Demonstrates ability to quickly build rapport and respond to customers in an empathetic manner by identifying and exceeding customer expectations.
 </li>
 <li>
 Listens attentively, captures relevant information, and identifies member or provider inquiries and concerns.
 </li>
 <li>
 Meets or exceeds individual performance goals established for the position in the areas of: call quality, attendance, adherence and other support center objectives.
 </li>
 <li>
 Proactively engages and collaborates with various internal/external stakeholders.
 </li>
 <li>
 Demonstrates personal responsibility and accountability by taking ownership of real-time solutioning and timely member and/or provider follow-up.
 </li>
 <li>
 Supports provider needs related to inquiries and assistance involving member eligibility and covered benefits, provider portal, and status of submitted claims.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 <ul>
 <li>
 Up to 1 year of customer service, call center and/or sales experience in a fast-paced/high-volume environment, or equivalent combination of relevant education and experience.
 </li>
 <li>
 Customer service skills.
 </li>
 <li>
 Data processing experience.
 </li>
 <li>
 Attention to detail, organizational and time-management skills, and ability to manage simultaneous tasks to meet business needs.
 </li>
 <li>
 Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA).
 </li>
 <li>
 Ability to establish and maintain positive and effective work relationships with coworkers, members, providers and customers.
 </li>
 <li>
 Effective verbal and written communication skills.
 </li>
 <li>
 Basic proficiency in Microsoft Office suite and applicable software programs.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Systems training/experience for the following : Microsoft Office, Microsoft Teams, Genesys, Salesforce, Pega, QNXT, CRM, Verint, video conferencing, CVS Caremark, Availity.
 </li>
 <li>
 Call center experience.
 </li>
 <li>
 Managed care/health care experience.
 
 
 </li>
 </ul>
 #PJCC3
 
 
 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: $14 - $24.02 / HOURLY
 
 
 <ul>
 <li>
 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
 
 
 </li>
 </ul>
</div>

Representative, Support Center

Join Molina Healthcare and explore 8   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.