Job Description
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.
