Role Description This is a remote position. Must reside in California. Under general supervision, responsible for auditing claims data and adjustments for accuracy of input and adjudication and facilitating the processing of assigned claims. Essential Functions: - Reviews claims, appeals, refunds, PLOGS, reinsurance cases, correspondence and other documents. - Identifies errors and analyzes to determine cause. - Documents findings and sends back for correction and adjudication. - Provides feedback and/or compiles and submits reports in a timely and accurate manner. - Monitors potential large loss claims; requests reimbursement for payments as required. - Collaborates with internal and external customers to answer questions, request information; sends required correspondence. Qualifications - In-depth knowledge of regulations governing Medi-Cal as they relate to claims processing. - In-depth knowledge of procedure coding and medical terminology, and their application in claims. - In-depth knowledge of general medical policy benefits and exclusions. - In-depth knowledge of industry standard payment practices. - In-depth knowledge of HPSJ systems as they relate to claims processing. - Basic leadership skills, including but not limited to the ability to influence without authority and motivate others. - Demonstrates a commitment to HPSJ’s strategy, vision, mission and values. - Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ. - Strong oral and written communication skills, with the ability to communicate professionally, effectively explain complex information, and document according to standards. - Ability to work independently and as part of a team. - Strong knowledge of basic data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity and recognize and act on trends. - Strong organizational skills, with the ability to prioritize and complete a wide variety of tasks. - Basic arithmetic skills. - Basic skills in Windows, Excel, Word and Outlook. - Ability to handle confidential information with appropriate discretion. - Ability to speak and be understood in English. Requirements - High school diploma or equivalent required. - Associate’s degree or higher in healthcare administration, business, or related field or: - Minimum of one-year internal adjustments and dispute specialist experience; or - Three years of experience in medical claims processing, adjustments, and quality assurance; and - Claims or medical billing/coding experience in healthcare field; or - Equivalent combination of education and experience. Preferred - Claims Medi-Cal and/or Managed Healthcare and Medicare auditing experience. - Billing/Coding Certificate or Medical Administrative Assistant Certificate. Licensure, Certification, Registration - CPB + CPC: Medical Billing and Coding certification, preferred. Benefits - Employee Wellness Program promoting physical, mental, and financial well-being. - Robust and affordable medical coverage including HMO and PPO plan options. - Dental and vision plan with multiple provider choices. - Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays). - CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan. - Two flexible spending accounts (FSAs) for healthcare and dependent care expenses. - Employer-Paid Term Life and AD&D Insurance. - Employer-Paid Disability Insurance. - Employer-Paid Assistance Program (EAP). - Health Advocacy to help you navigate medical care and benefits. - Voluntary supplemental benefits including medical, legal, identity theft protection. - Online discount mall. - Tuition reimbursement. - Remote work contingent on business needs and company guidelines. - A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do. Physical Demands - Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. - Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds. Emotional/Psychological Demands - Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations. Work Environment - Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. - For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards. Important Notice The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.

• Administer and configure dynamic routing protocols in multi-vendor environments. • Manage, deploy, and troubleshoot next-generation firewalls (NGFWs) and open-source solutions. • Actively monitor network health by defining and tracking key performance indicators (KPIs). • Ensure integration and security of Linux servers and firewalls with essential network services (DNS, VPN, etc.). • Automate repetitive infrastructure tasks to ensure standardization and operational efficiency.

Role Description We are seeking a new Analytics Operations team member to serve as Staff Analytics Portfolio & Process Governance. This role is responsible for establishing and optimizing the frameworks, tools, and processes that enable effective planning, execution, and governance of analytics work across the organization. Its critical to operate at both a strategic and operational levels, ensuring alignment between team-level execution and leadership priorities while driving consistency, transparency, and continuous improvement in how analytics work is planned and delivered. Responsibilities - Portfolio Framework Development & Governance - Define, implement, and continuously refine portfolio governance frameworks to support effective work planning across analytics teams. - Establish standardized approaches for prioritization, capacity planning, and roadmap development. - Ensure alignment between analytics initiatives and broader business objectives. - Drive strategy and alignment of Executive-level Portfolio KPIs and reporting. - Develop clear, scalable documentation for portfolio governance processes, standards, and workflows. - Work Planning Tool Ownership - Evaluate, select, and lead the implementation of a portfolio and collaboration tool that supports both team-level execution and leadership visibility. - Drive adoption and best practices for tool usage across portfolio team and analytics stakeholders. - Maintain and optimize the tool to ensure it meets evolving organizational needs. - Risk & Dependency Management - Design and operationalize processes for identifying, tracking, and escalating risks, issues, and cross-team dependencies. - Enable proactive communication and mitigation strategies across teams and leadership. - Ensure visibility and accountability for critical blockers impacting delivery. - Process Documentation & Excellence - Lead the design and optimization of end-to-end business processes, ensuring alignment with organizational strategy and operational goals. - Facilitate cross-functional workshops to gather requirements, map current-state processes, and identify opportunities for improvement. - Analyze process performance using data and metrics to identify bottlenecks, inefficiencies, and areas for automation. - Partner with stakeholders to design future-state workflows that enhance productivity, quality, and customer experience. - Collaborate with technology and analytics teams to integrate tools and systems that support optimized processes. - Drive organizational change efforts by developing transition plans, training materials, and communication strategies. Qualifications - Bachelor’s degree in business, data science, computer science, or a related field. - 12+ years of experience in analytics operations, portfolio management, program management, or related disciplines within large-scale organizations. - Proven ability designing and implementing work planning frameworks and operating models. - Authority in architecting and deploying portfolio and program management (PPM) tools such as Wrike (preferred), Aha!, Jira, AirTable, MS Project/Planning, Asana, etc. - Attention to detail with the ability to scale solutions. - Deep expertise in successfully implementing and managing agile delivery execution methodologies. - Excellent communication and presentation skills; able to influence technical and non-technical stakeholders at multiple levels – including VP-level and above. - Thrives in highly ambiguous environments to drive alignment across teams. - Unparalleled analytical and problem-solving skills, capable of operating at both tactical and leadership levels. - Driving force, collaborative, and comfortable operating in a fast-paced, global environment. - Continuous improvement mindset. - PMP (preferred), Six Sigma (black belt), or BPM process improvement certification or equivalent demonstrated experience. Requirements - Please refer to our Candidate Privacy Notice for more information about how we process your personal information, and your data protection rights. - At SIE, we consider several factors when setting each role’s base pay range, including the competitive benchmarking data for the market and geographic location. - Please note that the base pay range may vary in line with our hybrid working policy and individual base pay will be determined based on job-related factors which may include knowledge, skills, experience, and location. Benefits - This role is eligible for SIE’s top-tier benefits package that includes medical, dental, vision, matching 401(k), paid time off, wellness program, and coveted employee discounts for Sony products. - This role also may be eligible for a bonus package. Equal Opportunity Statement Sony is an Equal Opportunity Employer. All persons will receive consideration for employment without regard to gender (including gender identity, gender expression and gender reassignment), race (including colour, nationality, ethnic or national origin), religion or belief, marital or civil partnership status, disability, age, sexual orientation, pregnancy, maternity or parental status, trade union membership or membership in any other legally protected category. We strive to create an inclusive environment, empower employees and embrace diversity. We encourage everyone to respond. Sony Interactive Entertainment is a Fair Chance employer and qualified applicants with arrest and conviction records will be considered for employment.

Role Description Provides support through the investigation and resolution of disputes related to provider appeals, ensuring that claims adhere to correct billing standards and regulations. - Reviews coding-related provider claims denials by systematically examining medical records, denial reasons, submitted claims, and claim history, in accordance with applicable state, federal, and Molina guidelines, rules, and protocols, to determine whether the documentation substantiates the services rendered. - Conducts independent audits of non-medical records to verify billing accuracy, making decisions within designated authority to either overturn or uphold denials in a timely manner. - Generates and communicates the determination to the provider using appropriate letter language and providing any necessary guideline links. - Identifies, documents, and communicates any identified coding errors or inconsistencies, collaborating with appropriate internal department(s) to capture and track issues to ensure precise code editing and compliance. - Completes data points within internal applications to comply with auditing requirements used within the departments of Molina. - Actively participates in the enhancement of departmental processes to maintain alignment with current coding regulations and guidelines, while also refining internal procedures. Qualifications - At least 2 years of experience in medical coding or billing. - Active and unrestricted Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification. - Strong attention to detail and ability to independently read and comprehend the details of medical records. - Comfortable working in a production-centric environment with high quality standards. - Ability to use Microsoft Office including Outlook, Word, and Excel. Requirements - To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Benefits - Molina Healthcare offers a competitive benefits and compensation package. - Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.