Sr Analyst, Claims Research (Medicaid Claims) Remote at Molina Healthcare, Remote

Sr Analyst, Claims Research (Medicaid Claims) Remote at Molina Healthcare, remote. Contract. Est. up to $130k. Apply with swipeandhired.

Molina Healthcare is hiring for Senior Analyst, Claims Research. This position is fully remote.
Highly Qualified Candidates Will Have the Following Experience –

• Experience with medical claims, specifically Medicaid claims

• Handling provider claim disputes

• Advanced Excel user

• QNXT / QNXT Claims (preferred, not required)

• Ability to perform root-cause analysis, and resolve issues through system corrections, manual adjustments, or provider education to support claim accuracy

• Strong communication skills, both written and verbal

Essential Job Duties

• 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.

• 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.

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