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Molina Healthcare · 21 hours ago

Senior Analyst, Claims Research

200 Oceangate, Long Beach, CA, 90802, US

Full-time

Onsite

Senior Level

5+ years exp

Molina Healthcare is seeking a Senior Claims Research Analyst who will provide senior-level support for claims processing and research. This role involves leading complex claims projects, conducting root cause analysis, and ensuring compliance with regulatory requirements while driving continuous improvement in claims performance.

Health CareHospitalMedical

Responsibilities

Uses advanced analytical skills to conduct research and analysis for issues, requests, and inquiries of high priority claims projects

Assists with reducing re-work by identifying and remediating claims processing issues

Locate and interpret regulatory and contractual requirements

Expertly tailors existing reports or available data to meet the needs of the claims project

Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing error

Act as a senior claims subject matter expert, advising on complex claims issues and ensuring compliance with regulatory and contractual requirements

Leads and manages major claims research projects of considerable complexity, initiated through provider inquiries, complaints, or internal audits

Conducts advanced root cause analysis to identify and resolve systemic claims processing errors, collaborating with multiple departments to define and implement long-term solutions

Interprets regulatory and contractual requirements to ensure compliance in claims adjudication and remediation processes

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, presenting findings, progress updates, and results in a clear and actionable format

Takes the lead in provider meetings, when applicable, clearly communicating findings, proposed solutions, and status updates while maintaining a professional and collaborative approach

Proactively identifies and recommends updates to policies, SOPs, and job aids to improve claims quality and efficiency

Collaborates with external departments and leadership to define claims requirements and ensure alignment with organizational goals

Qualification

Medical claims processingRegulatory complianceRoot cause analysisProject managementClaims management systemsData analysis toolsMedical billing codesAnalytical skillsMicrosoft Office proficiencyExcel expertisePowerPoint expertiseOrganizational skillsProblem-solving skillsCommunication skills