**JOB DESCRIPTION** **Job Summary** Responsible for planning, developing, and directing the implementation of techniques to ensure the maintenance of performance and quality levels in the Business' products and processes. Reviews operation process designs and establishes procedures and techniques for operational standards. Confers with customers to define and resolve **KNOWLEDGE/SKILLS/ABILITIES** + Implements companywide initiatives relevant to Claims Production, i.e., Claims Production, Audit, Production Vendor Oversight. + Leads activities supporting the production of claims including but not limited to the Corporate Recovery Team, Corporate Claims Compliance Team, Support Services, Corporate Encounter Team as well as providing overall organizational leadership of claims editing and recovery vendors aimed at managing overall healthcare costs. + Engages with IT and other departments to implement changes to business processes and systems for Corporate Operations PMO + Implements Corporate Configuration of the QNXT system as well as the Care Management application for UM functions within QNXT and enables system to produce expected costs. + Ensures state regulatory requirements are met, maximizes MASS Adjudication within QNXT, improves process quality, reduces G&A costs, and continues to drive positive operational and financial outcomes within all initiatives.Hire, coordinate training, and manage staff involved in creating controls, documents, and tools within the Member/Provider Appeals & Grievances and Provider Dispute area. + Managing to Contract Requirements and adherence to performance metrics, inventory and resource management + Identify, develop, and train appropriate staff and implement processes to standardize the end-to-end processing of appeals and grievances. + Work with partner departments to implement process improvements impacting quality and timeliness of processing appeals and grievances. + Initiate and coordinate projects around Root Cause Analysis with upstream business partners, tracking and trending. + Enhance appeals & grievance processes and reduce unit appeal costs by reducing re-work for all lines of business. + Identify projects/initiatives that reduce administrative costs for Molina and/or providers to assist appeal in managing organizational healthcare costs. + Establish and manage budget forecasts and budgetary targets **JOB QUALIFICATIONS** **Required Education** Graduate Degree or equivalent combination of education and experience **Required Experience** 7-9 years To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $140,795 - $274,550 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.