**Job Description**

**Job Summary**

Provides lead level support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.

**Job Duties**

• Key contributor in enhancement of current processes, training, audits, and production management related to claims review and settlement processes.
• Develops tools and process improvements based on identified trends to ensure that claims are settled in a timely fashion and in accordance with quality reviews.
• Identifies potential claims outside of current concepts where additional opportunities may be available; suggests and develops high-quality, high-value concepts and/or process improvements and tools.
• Audits inpatient medical records for generat...