Job Summary
Responsible 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.
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 developed requirements.
Monitors sources to ensure all updates are aligned.
Leads coordinated development and ongoing management /interpretation review process, committee structure and timing with key partner organizations.
Conducts analysis to identify root cause and assist with problem management as it relates to state 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.
Provides support for requirement interpretation inconsistencies and complaints.
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.
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 is 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.
Required Qualifications
At least 2 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.
Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams.
Previous success in a dynamic and autonomous work environment.
Power BI
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.
Molina Healthcare is a managed care organization that provides health insurance and care management services, primarily serving Medicaid members. The company operates health plans and delivers integrated care coordination across the continuum of care, combining medical management with behavioral health, long-term services and supports (LTSS), and community resources. Molina employs advanced claims processing systems, risk adjustment methodologies, and quality performance management to ensure cost-effective, high-quality member outcomes. The company supports various health plans and regulatory requirements while managing complex operations including provider contracting, benefits configuration, and HEDIS audit compliance.
