Job Description
JOB DESCRIPTION Job Summary
Provides strategy and leadership for team responsible for encounters activities including monitoring inbound and outbound encounters processes and ensuring timely, accurate and complete encounter submissions for low to moderate complexity markets or states. Facilitates data and process analysis, collaborates with cross-functional teams to identify and resolve root-causes of issues that impact encounters, and provides recommendations for improvements to enhance operational performance.
Essential Job Duties
• Supports strategy development, vision and direction for the encounters function. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised.
• Demonstrates accountability for encounters accuracy and completeness (i.e., encounters production, audit, production vendor oversight) for assigned lines of business.
• Demonstrates accountability for increasing volume of encounters received from providers, improving completeness of encounter data with states, Centers for Medicare and Medicaid Services (CMS), and the Department of Health and Human Services (HHS) to reconcile data.
• Ensures encounter submissions, rejection management and resolution for all lines of business including internal strategic partnerships supporting the production of encounters, demonstrates leadership and accountability to support management of overall health care costs.
• Actively participates in the hiring process, coordinates training and manages staff involved in creating controls, documents, and tools within the encounter process to manage work in assigned resources.
• Identifies, develops and trains direct reporting encounters staff and implements processes to standardize the overall end-to-end processing, management and accuracy of encounters, and works collaboratively with departments to implement process improvements that impact quality, timeliness, and accuracy of encounters processing.
• Facilitates ongoing monitoring and management resolution for potential penalties related to accuracy and timeliness of encounters submissions.
• Manages encounters-related/operational projects/initiatives that reduce administrative costs for Molina and/or providers, and identifies opportunities to ensure accuracy of encounters and support for management of organizational health care costs for all lines of business directly impacting risk revenue and quality compliance.
• Partners with encounters senior leadership to ensure alignment of business goals and objectives for cost-saving initiatives.
• Convenes encounters-related work groups and develops implementation plans with identified tasks, timelines and delegation to assigned parties, and executes and measures success accordingly.
• Partners with encounters, operations, and IT leadership to analyze the root-cause of variations to encounters, find/propose ways to improve upon performance results, identify potential risks to the organization and lead changes within encounters processes to support organizational needs for all lines of business.
• Collaborates with leadership, peers, and business partners to establish encounters improvement objectives and execute business priorities based on strategic goals in the operational plan.
• Manages direct report staff and oversees vendors - enabling the organization to produce operational results at the lowest possible cost, the most consistent and compliant service levels, and at the highest level of quality for all lines of business.
• Ensures all state, federal and Molina regulations, policies/procedures and standard operating procedures (SOPs) are implemented and followed on a consistent basis to ensure the highest compliance possible within the encounters department.
• Assists encounters senior leadership with managing costs to meet/exceed annual budgets and find ways to improve productivity and automation wherever possible to reduce unit and general and administrative (G&A) costs for the organization.
• Identifies and implements systematic approaches to improve member and encounter first pass rate, and increase operational efficiency and effectiveness.
Required Qualifications
• At least 10 years of experience in billing, claims, encounters, and/or data analysis, preferably in a senior leadership capacity in a managed care setting, or equivalent combination of relevant education and experience.
• At least 5 years management/leadership experience.
• Expert knowledge of health care encounters.
• Advanced knowledge of data analysis techniques and experience writing basic to advanced queries.
• Previous experience/accountability for multiple markets or product lines.
• Experience with managing department budget within prescribed parameters.
• Experience with account management and vendor management.
• Ability to present complex operational information.
• Ability to work cross-collaboratively across teams/functions, and influence and drive change.
• Ability to envision, craft proposals, obtain consensus around approving and implementing future state processes and systems needed to support strategic direction set by organization.
• Strong understanding of technical solutions.
• Strong organizational and time management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Strong interpersonal and people leader skills.
• Excellent verbal and written communication skills.
• Microsoft Office suite and applicable software program(s) proficiency.
Preferred Qualifications
• Strong encounters operations/implementation/reporting, claims processing, provider contacting, health data analysis and reporting, and project management experience.
• Experience working with various levels of leadership in a highly matrixed organization.
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.
