Analyst, Claims Research - Full-time

JOB DESCRIPTION **Job Summary** Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution. **Essential Job Duties** • Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects. • Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams. • Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries/complaints, or legal requests. • Assists with reducing rework by identifying and remediating claims processing issues. • Locates and interprets claims-related regulatory and contractual requirements. • Tailors existing reports and/or available data to meet the needs of claims projects. • Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors. • Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes. • Seeks to improve overall claims performance, and ensure claims are processed accurately and timely. • Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance. • Works collaboratively with internal/external stakeholders to define claims requirements. • Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing. • Fields claims questions from the operations team. • Interprets, communicates, and presents, clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims. • Appropriately conveys claims-related information and tailors communication based on targeted audiences. • Provides sufficient claims information to internal operations teams that communicate externally with providers and/or members. • Collaborates with other functional teams on claims-related projects, and completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance. • Supports claims department initiatives to improve overall claims function efficiency. **Required Qualifications** • At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience. • Medical claims processing experience across multiple states, markets, and claim types. • Knowledge of claims processing related to inpatient/outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs. • Data research and analysis skills. • Organizational skills and attention to detail. • Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. • Ability to work cross-collaboratively in a highly matrixed organization. • Customer service skills. • Effective verbal and written communication skills. • Microsoft Office suite (including Excel), and applicable software programs proficiency. **Preferred Qualifications** • Health care claims analysis experience. • Project management 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 Pay Range: $21.16 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.