Analyst, Claims Research (Remote)-CT
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.
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: $21.82 - $42.55 / HOURLY
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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