About this role.
This Director role leads the configuration team responsible for accurate implementation and maintenance of claims databases, provider contracts, benefits, and fee schedules for managed care programs. The position requires strategic planning, process improvement, and stakeholder collaboration to ensure compliance and operational efficiency. Candidates need at least 8 years of healthcare operations experience and 3 years of leadership experience. The role demands expertise in QNXT/NetworX systems and advanced analytical skills. This is a senior leadership position with significant impact on claims processing and system configuration.
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Core skills
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Cover letter sample
I am writing to express my interest in the Director of Core Systems Strategies position. With over 10 years of experience in managed care operations, including 5 years in leadership roles, I have a proven track record of leading configuration teams and optimizing QNXT/NetworX systems. My expertise includes implementing provider contracts, fee schedules, and benefits while ensuring compliance with Medicaid and Medicare regulations.
I have successfully driven process improvements that reduced claims processing errors by 20% and improved on-time delivery. My strong analytical skills and ability to troubleshoot complex claim discrepancies align with the requirements of this role. I am eager to bring my strategic vision and operational excellence to your organization.
Thank you for considering my application. I look forward to discussing how my experience can contribute to your team's success.
Sample interview questions
I have over 8 years of hands-on experience with QNXT, where I configured provider contracts, fee schedules, and member benefits. I led a team that managed configuration for multiple health plans, ensuring accuracy and compliance with state and federal regulations. I also implemented automated validation processes to reduce errors.
I use a structured approach: first, I assess each project's impact and urgency with input from stakeholders. I then allocate resources based on team capacity and skill sets. I set clear milestones and hold regular check-ins to track progress. For example, during a recent system upgrade, I coordinated parallel workstreams and ensured on-time delivery by adjusting priorities as needed.
In my previous role, I identified that manual fee schedule updates were causing delays. I led the implementation of an automated fee schedule import tool, which reduced update time by 40% and eliminated errors. This also freed up the team to focus on more complex configuration tasks.
I establish a compliance framework that includes regular training sessions, a central repository for regulatory updates, and periodic audits. I also assign a compliance lead to monitor changes from CMS and state agencies. For instance, when new Medicaid rules were introduced, I organized workshops to update our configuration processes accordingly.
Once, a business stakeholder wanted to expedite a contract change that conflicted with our system's validation rules. I facilitated a meeting with the stakeholder and IT to explain the risk of errors. We agreed on a phased approach: first, a manual override with additional checks, then a system update to accommodate the change. This balanced business needs with data integrity.
JOB DESCRIPTION Job Summary
Leads and directs team responsible for configuration activities including accurate and timely implementation and maintenance of critical information on claims databases, validation of data stored on databases, and adherence to health plan business and system requirements as it pertains to contracting, benefits, prior authorizations, fee schedules and other business requirements.
Essential Job Duties
• Directs configuration team, and demonstrates accountability for team performance – including meeting or exceeding established performance targets; targets may be based upon specific health plan requirements, and/or federal/state requirements.
• Strategically plans, leads, and manages configuration workflow processes.
• Continuously identifies and executes opportunities for operational efficiencies and develops best practice approaches for assigned operational areas, ensuring achievement of organizational/department goals.
• Ensures appropriate resources are available to achieve department goals – escalates resource needs, rationale, and deficiencies to leadership.
• Identifies and implements strategic process improvements related to the configuration function that demonstrate return on investment (ROI).
• Establishes and maintains benefits, provider contracts, fee schedules, claims edits, and other system settings in the claim payment system.
• Directs the development and implementation of contract, benefit configuration, and fee schedules.
• Directs the implementation and maintenance of member benefits in the claims payment system and other applicable systems.
• Supports critical business strategies by providing systematic solutions and or recommendations on business processes.
• Plans for long-term success of the department and individual health plans – focusing on goals and improvements to daily operations.
• Builds and maintains strong trusted relationships with key stakeholders including health plan leadership and other cross-functional departments; presents data and opportunities to stakeholders and collaborates on performance improvement initiatives.
• Coordinates activities of assigned work function and/or department related activities ensuring efficiency and prioritization.
• Utilizes superior judgement in evaluating various approaches to limit risk, and communicates risk accordingly to appropriate stakeholders.
• Ensures appropriate follow-up and communication occurs on direct assignments, and activities and tasks that fall within the scope of configuration.
• Ensures team compliance with applicable federal/state regulations and internal policies/procedures.
• Hires, trains, develops and manages team; demonstrates accountability for team performance and achievement of configuration/department-specific goals.
Required Qualifications
• At least 8 years of configuration oversight, claims, auditing, and/or health care operations experience in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.
• At least 3 years of management/leadership experience.
• Advanced understanding of claims processes.
• Advanced ability to identify and troubleshoot claim discrepancies by utilizing benefit and provider contracts, regulatory requirements and various claims related resources.
• Strong analytical, critical-thinking, and problem-solving skills.
• Strong multitasking ability, and decision-making skills.
• Flexibility to meet changing business requirements, and strong commitment to high-quality/on-time delivery.
• Ability to work cross-collaboratively in a highly matrixed organization.
• High attention to detail.
• Excellent verbal and written communication skills.
• Microsoft Office suite proficiency, including advanced Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.
Preferred Qualifications
• Certified Professional Coder (CPC).
• Extensive experience leading analysis and operational teams in a managed care setting.
• Extensive experience collaborating with various levels of leadership in a highly matrixed organization.
• Deep claims system processing, configuration, and queries experience.
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
Annual salary information is not provided for this position. Explore salary ranges for similar roles in our Salary Directory ›
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