Job Details

JOB DESCRIPTION Job Summary

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution.

Essential Job Duties

• 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.

Required Qualifications

• 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.

Preferred Qualifications

• Health care claims analysis experience.Project management experience.

• QNXT

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

Pay Range: $17.85 - $38.69 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.