Registered Nurse - Home Health, Part Time

42141 Glasgow, Kentucky TJ Regional Health

Posted 7 days ago

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Job Description

JOB SUMMARY

The Home Health Registered Nurse administers skilled nursing service to home health patients and completes required documentation and records. The nurse supervises nurse aides and licensed practical nurses.

Performs back up nursing for Hospice.

Job Requirements

Minimum Education
  • Holds an active Registered Nurse license and is eligible to practice in the state of Kentucky.
  • Current BLS certification

Minimum Work Experience
  • Two years' experience as a licensed nurse.

FUNCTIONAL DEMANDS

Physical Requirements

Sitting - 16-31%

Walking - 1-15%

Standing - 1-15%

Bending/Squatting - 1-15%

Climbing/Kneeling - 1-15%

Twisting - 1-15%

OSHA Category

Minimal Potential for Direct Body Fluid Exposure

Visual and Hearing Requirements

Must be able to see with corrective eyewear.

Color vision ability required.

Must be able to hear clearly with assistance.

Other Physical/Environmental Demands

Lifting - 0-50lbs, 50lbs or more with assistance

Carrying - 0-50lbs, 50lbs or more with assistance

Pulling - up to 100lbs

Pushing - up to 100lbs

LEADERSHIP CAPABILITIES

Mission, Service, and Values

Supports the hospital Mission, Service and Values.

ESSENTIAL FUNCTIONS
  • Performs patient assessments as appropriate to specific age including OASIS information according to standards.
  • Provides direct nursing services as ordered by physician including specialized care to pediatric, adult, and geriatric patients.
  • Documents the delivery of patient care and visit records.
  • Supervises activities of the home health and hospice aides and licensed practical nurses.
  • Provides case management for Home and Community Based Services.
  • Completes forms and calls for prior approval for Home & Community Based Services, and EPSDT patients and assesses patients for First Steps Services.
  • Takes call as assigned by Home Health and/or Hospice Coordinator.
  • Educates patient and/or caregiver on disease management and consults with physician as needed.
  • Reviews, educates, and updates patient medications accurately and timely.
  • Explains philosophy, purpose, scope and role of hospice to patients/families.
  • Prepares and implements treatment plan for patient and family, in collaboration with the patient and family and other members of the interdisciplinary team.
  • Orders needed medications, supplies, and equipment.
  • Instructs caregivers in the proper use of medication, supplies and equipment, and in the basic skills required to care for the patient in the home.
  • Functions as a liaison between patient/family and other care providers of the interdisciplinary team.

ORGANIZATIONAL EXPECTATIONS

T.J. Pledge

I Will Show Compassion

-see all patients, family members, coworkers, physicians, and anyone else at T.J. as my customer.

-recognize that each and every interaction I have at T.J. Regional Health matters

-show kindness and compassion towards my customers at all times

-be sensitive to the personal and private needs of every customer

I Will Cooperate With Others

-maintain zero tolerance for abusive behavior

-listen and be willing to accept fault when I make a mistake

-never underestimate the power of an apology

-refrain from blame and judgment

-bring a sense of calm to stressful situations

I Will Collaborate With Others

-value myself and every coworker as an equal part of one GREAT team working together

-treat others in a way that I would like to be treated

-participate only in conversations that are courteous, respectful, and reflect positively on my teammates and T.J. Regional Health

-foster a calm and pleasant atmosphere, and refrain from gossip, rumors, and insults

-speak honestly, seek truth, and act with integrity towards my teammates

-value the uniqueness and expertise that each team member contributes to the whole

-meet the need of the moment, regardless of whether or not it is considered part of my job

I Will Communicate

-smile - at everyone

-always introduce myself, my role, and my purpose use body language, eye contact, and tone of voice that shows respect in every interaction

-follow the 10/5 rule: always acknowledging people at 10 feet away with a smile and always greeting people at 5 feet away

-escort any customer in need (visitors, patients) to their destination

I Will Adapt To Change

-be a part of the solution when I am presented with a challenge

-embrace change and set the example for those around me

-accept openly when there are changes that T.J. Regional and/or I have no control over

-manage the expectations of others by explaining duration and next steps as often as needed

I Will Be A Champion

-serve with passion

-view myself as an owner of T.J. Regional Health and act accordingly

-take responsibility for the physical appearance of T.J. Regional Health, including my work area

-go out of my way to daily thank and compliment my customers and coworkers

-dare to make a difference and be exceptional

-constantly try to improve myself and T.J. Regional Health

-speak positively about T.J. Regional, while at work and in public places outside of work

#TJRegionalHealth10

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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In Home Caregiver Weekends

42142 Glasgow, Kentucky Sevita

Posted 6 days ago

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Job Description

Just Family Center, a part of the Sevita family, provides home and community-based services including day programs for elders with complex medical or rehabilitative needs, attendant care and case management. This allows seniors to obtain quality healthcare while remaining active and involved in the community and continuing to live in their own homes. Our programs are staffed with qualified, experienced licensed nurses and caregivers who are trained to provide individual assistance to each person we serve.Life Skills Trainer/Caregiver We are offering $14.00 per hour for Caregivers and $3 shift differential on weekends! Relief positions available. Would you like to make a difference every day in someone’s life? In this role you will carry out rewarding work and play a crucial role in the success of our organization. Provide training, assistance and supervision to individuals receiving care in the areas of living skills, therapeutic recreation, and other forms of assistance in both residential and community settings. Assist with daily activities such as meal preparation, personal hygiene, shopping, cleaning, and medication administration. Facilitate the working relationships between employers and individuals served, and support community involvement by accompanying them on outings, or providing transportation to work or other activities. Work closely with our clinical staff to support the therapeutic and behavioral plans in place. Qualifications: High School Diploma or GED equivalent Six months to one year of experience in the human services field Valid Driver's License from state of residence (Must have 2yr post permit driving experience) Must be minimum of 18 years of age Successful clearance of background checks A caring attitude with a dedication to assisting others Strong attention to detail, organizational skills, and effective communication skills A reliable, responsible attitude and a compassionate approach A commitment to quality in everything you do Whether you have previous experience in a role like this, or this just sounds like the type of impact you want to make… we want to hear from you! Why Join Us? Full, Part-time, and As Needed schedules available Full compensation/benefits package for full-time employees Paid training, Holiday pay, Mileage reimbursement Career development and advancement opportunities Work with some of the best co-workers you could ask for and see your impact on the lives of those individuals we serve A dynamic work environment where no day is ever the same as the next Since our funding comes from Federal and State payers, we offer stability, and secure work opportunities Work with fantastic co-workers - Come join our team – Apply Today! Sevita is a leading provider of home and community-based specialized health care. We believe that everyone deserves to live a full, more independent life. We provide people with quality services and individualized supports that lead to growth and independence, regardless of the physical, intellectual, or behavioral challenges they face. We’ve made this our mission for more than 50 years. And today, our 40,000 team members continue to innovate and enhance care for the 50,000 individuals we serve all over the U.S. As an equal opportunity employer, we do not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, citizenship, or any other characteristic protected by law.

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CT Technician PRN

42103 Mammoth Cave, Kentucky TriStar Greenview Regional Hospital

Posted 7 days ago

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Job Description

Description Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity. We care like family! Jump-start your career as a CT Tech today with TriStar Greenview Regional Medical Center.BenefitsTriStar Greenview Regional Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.Free counseling services and resources for emotional, physical and financial wellbeing401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)Employee Stock Purchase Plan with 10% off HCA Healthcare stockFamily support through fertility and family building benefits with Progyny and adoption assistance.Referral services for child, elder and pet care, home and auto repair, event planning and moreConsumer discounts through Abenity and Consumer DiscountsRetirement readiness, rollover assistance services and preferred banking partnershipsEducation assistance (tuition, student loan, certification support, dependent scholarships)Colleague recognition programTime Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.Learn more about Employee BenefitsNote: Eligibility for benefits may vary by location.Our teams are a committed, caring group of colleagues. Do you want to work as a CT Technologist where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!Job Summary and QualificationsThe CT Technologist is responsible for performing a variety of imaging procedures ordered by the physician?CT Technologist?are responsible for?day-to-day activities to ensure the delivery of quality patient care in a diagnostic/therapeutic environment?What you will do in this role:?You will?demonstrate?the knowledge and skills necessary to provide?appropriate care?for patient populations served in?the department?You will?demonstrate?knowledge of the principles of growth and development over the life span and?possess?the ability to assess data reflective of the patient’s requirements?relative?to his/her age-specific needs?You will assess patients/families?ability to learn and incorporate teaching?throughout CT procedure?You will deliver compassionate, holistic care, while supporting the rights and dignity of all patients?What qualifications you will need:?Must be a graduate of an accredited 24-month Radiological Technology Program?Basic Life Support (BLS) certification, current?ARRT registered; CT Certification or?acquired?within 6 months?1-3 years?minimum?CT Experience? TriStar Greenview Regional Hospital is a 200+ bed facility serving Southern Kentucky and surrounding areas. Recognized by the Joint Commission as a?Top Performer on Key Quality Measures, TriStar Greenview is a national leader in providing quality healthcare?Home of Kentucky's first CardioMEMS HF System, we are also an accredited chest pain center that provides state-of-the-art cardiac care to patients managing heart failure. The facility is also a Certified Primary Stroke Center?"Bricks and mortar do not make a hospital. People do."- Dr. Thomas Frist, Sr.HCA Healthcare Co-FounderIf you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our CT Technologist opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews?Unlock the possibilities and apply today! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

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Specialist, Configuration Oversight (Healthcare Claims Adjudication experience)

42103 Mammoth Cave, Kentucky Molina Healthcare

Posted 9 days ago

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Job Description

Job Description

Job Summary

Responsible for conducting various audits including, but not limited to; vendor, focal, audit the auditor. Confirm that documentation is clear and concise to ensure accuracy in auditing of critical information on claims ensuring adherence to business and system requirements of customers as it pertains to contracting (benefit and provider), network management, credentialing, prior authorizations, fee schedules, and other business requirements critical to claim accuracy. Maintain audit records, and provide counsel regarding coverage amount and benefit interpretation within the audit process. Provide clear and concise results and comments to leaders about focal audits. Contributes to completion of audits as needed to ensure audits are conducted in a timely fashion and in accordance with audit standards.

Job Duties

• Reviews documentation regarding updates/changes to member enrollment, provider contract, provider demographic information, and/or claim processing guidelines. Evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core processing system (QNXT).

• Conducts focal audits on samples of processed transactions impacted by these updates/changes. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.

• Conducts audits of vendor audits and verifies accuracy of their published outcomes are aligned to the documentation, various sources of truth and being assessed appropriately.

• Clearly documents the focal audit results and makes recommendations as necessary.

• Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 30 days of error issuance.

• Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims. ( Use for claims specific positions only )

• Prepares, tracks and provides audit findings reports according to designated timelines

• Presents audit findings and makes recommendations to management for improvements based on audit results.

Job Qualifications

REQUIRED EDUCATION:

Associate’s Degree or equivalent combination of education and experience

REQUIRED EXPERIENCE, SKILLS & ABILIITIES:

  • Minimum 2 years as an operational auditor for at least one core operations function

  • Previous examiner/processing experience in at least one core operations functional area

  • Strong attention to detail

  • Knowledge of using Microsoft applications to include; Excel, Word, Outlook, Powerpoint and Teams

  • Ability to effectively communicate written and verbal

  • Knowledge of verifying documentation related to updates/changes within claims processing system .

  • Experience using claims processing system (QNXT).

PREFERRED EDUCATION:

Bachelor’s Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

3+ years

Healthcare Claims Adjudication

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

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: $21.16 - $42.2 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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Senior Analyst, Healthcare Analytics - ETL

42103 Mammoth Cave, Kentucky Molina Healthcare

Posted 24 days ago

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Job Description

JOB DESCRIPTION

Job Summary

JOB SUMMARY:

The Sr. Analyst, Healthcare plays a critical role in supporting clinical and operational initiatives by translating healthcare business needs into technical solutions. This role works closely with clinicians, care management teams, and business stakeholders to gather requirements and deliver actionable insights through data analytics. The ideal candidate brings a strong foundation in SQL, Power BI, Databricks, Snowflake, and ETL development, along with a collaborative approach to building scalable, healthcare-focused data solutions.

JOB DUTIES:

  • Partner with clinical, operational, and business teams to understand data needs and translate requirements into actionable technical solutions.

  • Write advanced SQL queries to extract, validate, and analyze healthcare data, including claims, pharmacy, and lab datasets.

  • Build and maintain efficient ETL pipelines to support ongoing reporting and analytics workflows.

  • Utilize Databricks and Snowflake to develop scalable data pipelines and analytical datasets.

  • Create and maintain Power BI dashboards to deliver insights on utilization, outcomes, and cost drivers across the organization.

  • Ensure data quality, governance, and documentation standards are met in all analytics work.

  • Support ad hoc data requests and collaborate cross-functionally to drive data-informed decisions in clinical and business operations.

  • Maintain fluency in healthcare data types (e.g., ICD/CPT codes, HEDIS measures, member eligibility) to guide technical decisions.

REQUIRED EDUCATION:

  • Bachelor's or Associate's degree in Data Science, Computer Science, Analytics, Information Systems, Engineering, or other technology-related fields

REQUIRED EXPERIENCE / SKILLS:

  • 3-5 years of experience working with healthcare data in an analytics or data engineering capacity

  • Advanced proficiency in SQL for large dataset analysis and transformation

  • Experience using Power BI for developing interactive dashboards and data visualizations

  • Hands-on experience with Databricks , Snowflake , or enterprise cloud data platforms

  • Solid understanding of ETL concepts and experience building pipelines for healthcare analytics

  • Strong communication and collaboration skills to work with clinical and business stakeholders

PREFERRED EXPERIENCE:

  • 4+ years in a healthcare analytics role supporting care management, population health, or quality improvement

  • Experience working directly with clinicians, nurses, or case management teams

  • Familiarity with risk adjustment, value-based care models, or healthcare performance metrics

  • Understanding of regulatory and compliance considerations (e.g., HIPAA) in data handling

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: $77,969 - $155,508 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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RN Program Manager, Healthcare Services

42102 Bowling Green, Kentucky Molina Healthcare

Posted today

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Job Description

**JOB DESCRIPTION**
**Job Summary**
This position will require an active RN license. Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
**KNOWLEDGE/SKILLS/ABILITIES**
+ In collaboration with others, plans and executes internal Healthcare Services projects and programs involving department or cross-functional teams of subject matter experts, delivering products from the design process to completion.
+ Manages programs providing ongoing communication of goals, evaluation, and support to ensure compliance with standardized protocols and processes.
+ May engage and oversee the work of external vendors.
+ Focuses on process improvement, organizational change management, program management and other processes relative to the business.
+ Serves as a subject matter expert and leads programs to meet critical needs.
+ Communicates and collaborates with customers to analyze and transform needs and goals into functional requirements.
+ Works with operational leaders within the business to provide recommendations for process improvement opportunities.
+ Conducts quality audits to assess Molina Healthcare Services staff educational needs and service quality and implement quality initiatives within the department as appropriate.
+ Creates business requirements documents, test plans, requirements traceability matrix, user training materials and other related documentations.
**JOB QUALIFICATIONS**
**Required Education**
+ Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license.
+ OR Bachelor's or master's degree in Nursing, Gerontology, Public Health, Social Work or related field.
**Required Experience**
+ 5+ years of managed healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, care transition and/or disease management.
+ Minimum 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff.
+ Experience working within applicable state, federal, and third party regulations.
**Required License, Certification, Association**
+ If licensed, license must be active, unrestricted and in good standing.
+ Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
**Preferred Education**
Master's Degree preferred.
**Preferred Experience**
+ 3+ years supervisory/management experience in a managed healthcare environment.
+ Medicaid/Medicare Population experience with increasing responsibility.
+ 3+ years of clinical nursing experience.
**Preferred License, Certification, Association**
Any of the following:
Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.
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: $77,969 - $142,549 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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Analyst, Healthcare Analytics - SQL/Power BI/Databricks - Remote

42102 Bowling Green, Kentucky Molina Healthcare

Posted today

Job Viewed

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Job Description

**JOB DESCRIPTION**
**Job Summary**
Performs research and analysis of complex healthcare claims data, pharmacy data, and lab data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and cost containment reports and makes recommendations based on relevant findings.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Develop ad-hoc reports using SQL programming, SQL Server Reporting Services (SSRS), Medinsight, RxNavigator, Crystal Reports, Executive Dashboard, and other analytic / programming tools as needed.
+ Generate and distribute standard reports on schedule using SQL, Excel, and other reporting software.
+ Collects and documents report / programming requirements from requestors to ensure appropriate creation of reports and analyses. Uses peer-to-peer review process and end-user consultation to reduce report writing errors and rework.
+ Identify and complete report enhancements/fixes; modify reports in response to approved change requests; retain old and new report design for audit trail purposes.
+ Analyze data sets and trends for anomalies, outliers, trend changes, and opportunities.
+ Create comprehensive workflows for the production and distribution of assigned reports, document reporting processes and procedures.
+ Assist with completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
+ Demonstrate Healthcare experience in Quantifying, Measuring and Analyzing Financial and Utilization Metrics of Healthcare.
**JOB QUALIFICATIONS**
**Required Education**
Bachelor's Degree in Finance, Economics, Math, Computer Science; or equivalent experience **Required Experience**
+ 2-4 years increasingly complex database and data management responsibilities
+ Basic knowledge of SQL
+ 2-4 years of increasingly complex experience in quantifying, measuring, and analyzing financial/performance management metrics
**Preferred Education**
Bachelor's Degree in Finance, Economics, Math, or Computer Science
**Preferred Experience**
Preferred experience in Medical Economics and Strong Knowledge of Performance Indicators:
+ Proactively identify and investigate complex suspect areas regarding medical cost issues
+ Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan
+ Apply investigative skill and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modeling, etc.
+ Analysis and forecasting of trends in medical costs to provide analytic support for finance, pricing and actuarial functions
+ Excel, Visio, Access
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: $77,969 - $128,519 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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Senior Analyst, Healthcare Analytics

42102 Bowling Green, Kentucky Molina Healthcare

Posted today

Job Viewed

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Job Description

**JOB DESCRIPTION**
**JOB DESCRIPTION**
**Job Summary**
The Senior Analyst, Healthcare plays a critical role in supporting clinical and operational initiatives by translating healthcare business needs into technical solutions. This role works closely with clinicians, utilization management teams, and business stakeholders to gather requirements and deliver actionable insights through data analytics. The ideal candidate brings a strong foundation in SQL, Power BI, Databricks, Snowflake, and ETL development, along with a collaborative approach to building scalable, healthcare-focused data solutions.
**KNOWLEDGE/SKILLS/ABILITIES**
- Partner with clinical, operational, and business teams to understand data needs and translate requirements into actionable technical solutions.
- Write advanced SQL queries to extract, validate, and analyze healthcare data, including claims, authorization, pharmacy, and lab datasets.
- Build and maintain efficient ETL pipelines to support ongoing reporting and analytics workflows.
- Utilize Databricks and Snowflake to develop scalable data pipelines and analytical datasets.
- Create and maintain Power BI dashboards to deliver insights on utilization, outcomes, and cost drivers across the organization.
- Ensure data quality, governance, and documentation standards are met in all analytics work.
- Support ad hoc data requests and collaborate cross-functionally to drive data-informed decisions in clinical and business operations.
- Maintain fluency in healthcare data types (e.g., ICD/CPT codes, HEDIS measures, member eligibility) to guide technical decisions.
**JOB QUALIFICATIONS**
**Required Education**
- Bachelor's or Associate's degree in Data Science, Computer Science, Analytics, Information Systems, Engineering, or other technology-related fields
**Required Experience**
+ 3-5 years of experience working with **healthcare data** in an analytics or data engineering capacity
+ Advanced proficiency in **SQL** for large dataset analysis and transformation
+ Experience using **Power BI** for developing interactive dashboards and data visualizations
+ Hands-on experience with **Databricks** , **Snowflake** , or enterprise **cloud data platforms**
+ Solid understanding of **ETL concepts** and experience building pipelines for healthcare analytics
+ Strong communication and collaboration skills to work with clinical and business stakeholders
**Preferred Experience**
+ 4+ years in a healthcare analytics role supporting **utilization management, population health, or quality improvement**
+ Experience working directly with **clinicians, nurses, or case management teams**
+ Familiarity with risk adjustment, value-based care models, or healthcare performance metrics
+ Understanding of regulatory and compliance considerations (e.g., HIPAA) in data handling
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: $77,969 - $155,508 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
View Now

Specialist, Configuration Oversight (Healthcare Claims Adjudication experience)

42102 Bowling Green, Kentucky Molina Healthcare

Posted today

Job Viewed

Tap Again To Close

Job Description

**Job Description**
**Job Summary**
Responsible for conducting various audits including, but not limited to; vendor, focal, audit the auditor. Confirm that documentation is clear and concise to ensure accuracy in auditing of critical information on claims ensuring adherence to business and system requirements of customers as it pertains to contracting (benefit and provider), network management, credentialing, prior authorizations, fee schedules, and other business requirements critical to claim accuracy. Maintain audit records, and provide counsel regarding coverage amount and benefit interpretation within the audit process. Provide clear and concise results and comments to leaders about focal audits. Contributes to completion of audits as needed to ensure audits are conducted in a timely fashion and in accordance with audit standards.
**Job Duties**
- Reviews documentation regarding updates/changes to member enrollment, provider contract, provider demographic information, and/or claim processing guidelines. Evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core processing system (QNXT).
- Conducts focal audits on samples of processed transactions impacted by these updates/changes. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.
- Conducts audits of vendor audits and verifies accuracy of their published outcomes are aligned to the documentation, various sources of truth and being assessed appropriately.
- Clearly documents the focal audit results and makes recommendations as necessary.
- Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 30 days of error issuance.
- Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims. ( _Use for claims specific positions only_ )
- Prepares, tracks and provides audit findings reports according to designated timelines
- Presents audit findings and makes recommendations to management for improvements based on audit results.
**Job Qualifications**
**REQUIRED EDUCATION:**
Associate's Degree or equivalent combination of education and experience
**REQUIRED EXPERIENCE, SKILLS & ABILIITIES:**
+ Minimum 2 years as an operational auditor for at least one core operations function
+ Previous examiner/processing experience in at least one core operations functional area
+ Strong attention to detail
+ Knowledge of using Microsoft applications to include; Excel, Word, Outlook, Powerpoint and Teams
+ Ability to effectively communicate written and verbal
+ Knowledge of verifying documentation related to updates/changes within claims processing system .
+ Experience using claims processing system (QNXT).
**PREFERRED EDUCATION:**
Bachelor's Degree or equivalent combination of education and experience
**PREFERRED EXPERIENCE:**
3+ years
Healthcare Claims Adjudication
**PHYSICAL DEMANDS:**
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.
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: $21.16 - $42.2 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
View Now
 

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  37. handyman Installation & Maintenance
  38. policy Insurance
  39. code IT & Software
  40. gavel Legal
  41. sports_soccer Leisure & Sports
  42. inventory_2 Logistics & Warehousing
  43. supervisor_account Management
  44. supervisor_account Management Consultancy
  45. supervisor_account Manufacturing & Production
  46. campaign Marketing
  47. build Mechanical Engineering
  48. perm_media Media & PR
  49. local_hospital Medical
  50. local_hospital Military & Public Safety
  51. local_hospital Mining
  52. medical_services Nursing
  53. local_gas_station Oil & Gas
  54. biotech Pharmaceutical
  55. checklist_rtl Project Management
  56. shopping_bag Purchasing
  57. home_work Real Estate
  58. person_search Recruitment Consultancy
  59. store Retail
  60. point_of_sale Sales
  61. science Scientific Research & Development
  62. wifi Telecoms
  63. psychology Therapy
  64. pets Veterinary
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