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Molina Healthcare · 2 weeks ago

Analyst, Claims Research (Remote)

United States

Full-time

Remote

Mid Level

3+ years exp

Molina Healthcare is a leading provider in the healthcare sector, and they are seeking an Analyst for Claims Research. The role involves providing analytical support for claims research activities, ensuring regulatory compliance, and collaborating with various departments to improve claims processing efficiency.

Health CareHospitalMedical

Responsibilities

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

Qualification

Medical claims processingData researchAnalysisClaims processing knowledgeMicrosoft Office proficiencyProject managementCustomer service skillsOrganizational skillsTime-management skillsEffective communication

Required

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