Senior Analyst, Claims Research

JOB DESCRIPTION Job Summary

Must reside in Florida.

Provides senior level analyst support for claims research activities. Ensures timely and accurate resolution of provider submitted claims issues/inquiries. Leverages deep understanding of medical claims processing, analytical skills, root-cause analysis, and regulatory interpretation to effectively triage issues to facilitate complex/high priority claims investigation or correction. Develops remediation strategies, ensures timely and accurate claims project execution, and drives continuous improvement in claims performance and compliance.

Essential Job Duties

• Leverages claims subject matter expertise and advanced analytical skills to conduct research and analysis for provider claims issues, requests, and inquiries, and provide recommendation for remediation and resolution.
• Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing errors.
• Advises on complex claims issues and ensures compliance with regulatory and contractual requirements.
• 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.
• Assists with reducing re-work by identifying and remediating claims processing issues.
• Conducts root-cause analysis to identify and resolve systemic claims processing errors.
• Locates and interprets regulatory and contractual requirements to ensure compliance in claims adjudication and remediation processes.
• Expertly tailors existing reports or available data to meet the needs of the claims research issue/project.
• Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational claims fixes.
• Leads and manages complex claims research projects initiated through provider inquiries, complaints, internal audits, or legal requests.
• Develops, tracks, and/or monitors remediation plans, ensuring claims reprocessing projects are completed accurately and on time.
• Provides in-depth analysis and insights to leadership and operational teams; presents findings, progress updates, and results in a clear and actionable format.
• Takes lead in provider update meetings; clearly communicates findings, proposed solutions, and status updates.
• Fields claims questions from the operations team.
• Appropriately conveys claims-related information and tailors communication based on targeted audiences
• Proactively identifies and recommends updates to policies, standard operating procedures (SOPs), and job aids to improve claims quality and efficiency.
• Collaborates with internal/external departments and leadership to define claims requirements and ensure alignment with organizational goals.
• Collaborates with multiple departments to define and implement long-term solutions related to claims issues and efficiencies.
• Collaborates with cross-functional teams on claims-related projects; completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance.
• Provides training, mentoring and support to new and existing claims research team members.

Required Qualifications

• At least 3 years of experience in medical claims processing/research and/or health care operations, or equivalent combination of relevant education and experience.
• Strong medical claims processing experience across multiple states, markets, and claim types.
• Advanced experience with Medicaid, Medicare, and Marketplace claims.
• Advanced knowledge of medical billing codes and claims adjudication processes.
• Advanced proficiency in claims management systems and data analysis/research tools.
• Expertise in regulatory and contractual claims requirements and root-cause analysis.
• Strong 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.
• Strong customer service skills.
• Strong analytical and problem-solving skills.
• Ability to work independently and as part of a team, and collaborate cross-functionally across a highly matrixed organization.
• Experience with process improvement methodologies.
• Project management experience.
• Effective verbal and written communication skills, and ability to tailor complex information for diverse audiences, including senior leadership and providers.
• Microsoft Office suite (including Excel), and applicable software programs proficiency.

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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