Jobs at Molina Healthcare Inc.

Leads national healthcare quality performance initiatives, including HEDIS reporting, quality data collection, analytics, forecasting, regulatory compliance, and performance improvement. Oversees data ingestion and quality strategies involving EHR, HIE, and supplemental data; resolves complex issues; coordinates cross-functional stakeholders and vendors; manages program deliverables, risks, documentation, and audit readiness. Provides subject matter expertise and guidance across quality initiatives.

Leads quality systems teams and manages quality data, performance improvement initiatives, regulatory submissions, analytics, audits, and project portfolios. Oversees HEDIS and NCQA-related activities, develops strategies to improve data completeness and close care gaps, manages resources and deliverables, mitigates risks, and communicates recommendations to leadership. Hires, coaches, and develops staff while ensuring compliance with healthcare quality strategies and managed care requirements.

Leads national risk and quality solutions for state health plans, providing managed-care expertise, coordinating implementation of action plans, identifying barriers, and driving performance improvement initiatives. Partners with health plan and corporate stakeholders, develops business cases and strategies, supports compliance, and facilitates risk and quality programs. The role requires extensive managed-care experience, risk adjustment knowledge, data analysis, project management, leadership, and familiarity with CMS initiatives, HEDIS, and NCQA.

Manages national healthcare quality performance initiatives, including quality data collection, analytics, reporting, ingestion validation, regulatory audit readiness, and care-gap improvement. Coordinates cross-functional stakeholders, vendors, project deliverables, documentation, and status reporting. Requires healthcare quality knowledge, data analysis skills, and familiarity with HEDIS, NCQA, CMS, claims coding, and managed care programs.

Leads interpretation of regulatory, contractual, benefit, and claims requirements and translates them into system configuration specifications. Supports governance, implementation, testing, defect resolution, reporting, compliance, and financial-impact analysis across health plans and products. Serves as a configuration subject matter expert, leads cross-functional projects, maintains regulatory information, improves configuration standards, and trains team members in a remote, multi-time-zone environment.

Reviews and resolves provider coding-related claim denials by examining medical records, claims, denial reasons, and billing guidelines. Conducts audits, determines whether to uphold or overturn denials, communicates decisions to providers, identifies coding errors, documents findings, and collaborates across departments to support compliance and process improvements.

Leads enterprise architecture strategy, roadmaps, standards, systems integration, cloud implementations, and complex IT transformation initiatives. Provides technical leadership for enterprise rollouts, mergers and acquisitions, cross-functional programs, and scalable technology solutions. Translates business requirements into architectures, evaluates technology trends, improves processes, briefs executives, and mentors architecture teams. Requires extensive enterprise architecture, systems integration, cloud, data analysis, healthcare payer, project management, and stakeholder leadership experience.

Provides entry-level support for maintaining provider demographic, affiliation, and contract data in claims and provider databases. Loads and updates provider information in QNXT using manual and automated tools, validates records against business and system requirements, audits data for quality and financial accuracy, and ensures accurate information for claims processing, reporting, and provider directories. The role includes paid QNXT and state-specific training.

Leads the design and delivery of scalable analytics solutions using Azure Databricks, Power BI, and related platforms. Transforms and validates structured and unstructured data, applies statistical techniques, develops dashboards and analytical models, and implements data governance and quality processes. Partners with business and technology stakeholders to translate requirements into technical solutions, provides peer guidance, monitors data trends, and communicates actionable insights to technical and non-technical audiences.

Leads complex business and technology programs across the full lifecycle, coordinating multiple project teams and stakeholders. Develops integrated plans, manages dependencies, risks, scope, timelines, resources, and budgets, and tracks program KPIs. Facilitates governance meetings, communicates status and outcomes to leadership, maintains documentation, supports decision-making, and drives alignment with business priorities. May mentor team members and coordinate continuous improvement activities.

Supports provider network administration by validating, maintaining, auditing, and entering provider demographic, affiliation, fee schedule, and claims information into health plan systems. Reviews data for accuracy, resolves configuration issues with internal teams, provides documented quality feedback, and assists with provider network projects while meeting deadlines and business requirements.

Reviews healthcare contracts and claims to validate QNXT configuration, provider contracts, benefits, fee schedules, coding, reimbursements, and payment accuracy. Audits claims for processing errors, fraud, waste, overpayments, and regulatory compliance. Documents findings, maintains audit workbooks, tracks follow-up actions, interprets state and federal requirements, and recommends system or process improvements to stakeholders and management.

Leads engineering support and architecture for enterprise-scale healthcare data platforms on Azure. Designs Databricks, Synapse, Data Factory, and Data Lake solutions; builds batch and real-time pipelines, analytical data models, BI solutions, and automated data quality frameworks. Implements machine learning and AI-assisted development, integrates low-code systems, ensures HIPAA compliance, and translates business needs into technical solutions. Mentors engineers, resolves technical issues, supports Agile delivery, and partners with healthcare business leaders on Medicare and Medicaid analytics initiatives.

Leads cross-functional process improvement and operational excellence initiatives across healthcare member, provider, sales, agent, and campaign operations. Serves as a Salesforce subject-matter expert, supporting CRM workflows, integrations, requirements, testing, reporting, and production validation. Partners with Genesys, analytics, technology, product, vendor, and business teams to identify process gaps, define future-state workflows, improve data integrity, and deliver measurable operational outcomes.

Reviews and resolves member and provider claims appeals, disputes, grievances, and complaints. Researches medical records, claims guidelines, contracts, benefits, fee schedules, and system configurations to determine outcomes and identify payment errors. Prepares compliant correspondence, appeal summaries, and provider reconsideration responses while meeting regulatory and departmental timelines. Communicates resolutions to members, providers, and authorized representatives and documents findings accurately.

Reviews and resolves member and provider appeals, grievances, disputes, and complaints within CMS, state, federal, and company timelines. Researches claims, medical records, contracts, benefits, fee schedules, and system configurations to determine outcomes and root causes of payment errors. Prepares accurate appeal summaries and regulatory correspondence, communicates resolutions, processes reconsideration requests, and documents findings while meeting production standards.

Reviews and resolves member and provider appeals, grievances, disputes, and claims complaints. Researches medical records, claims guidelines, contracts, benefits, fee schedules, and system configurations to determine outcomes and payment-error root causes. Prepares compliant appeal summaries, correspondence, claim adjustments, and responses while meeting regulatory and departmental production timelines. Communicates resolutions to members, providers, and authorized representatives.

Analyzes and interprets regulatory and functional requirements for health plan coverage, reimbursement, and processing systems. Develops requirement documentation, monitors policy updates, coordinates stakeholder reviews, supports governance committees, investigates compliance-related root causes, and communicates impacts to health plans, product teams, and leadership. Maintains regulatory data, supports issue resolution, and ensures traceability of requirement changes across business functions.

Analyzes healthcare claims, pharmacy, laboratory, financial, utilization, and risk-adjustment data. Develops suspect, targeting, tracking, QA, and reporting systems for Medicaid, Marketplace, Medicare, and MMP interventions. Performs predictive modeling, statistical analysis, forecasting, anomaly detection, data validation, root-cause analysis, and risk-score tracking. Communicates analytical findings to technical and nontechnical stakeholders while supporting cross-functional projects and regulatory or business requests.

Manages payment integrity programs and recovery operations, overseeing staff, quality assurance, performance metrics, workflows, vendor relationships, regulatory compliance, and process improvement. Analyzes operational data to improve recovery effectiveness, cost avoidance, accuracy, and audit readiness while supporting CMS and state requirements.