Analyst, Claims Research

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 u2022 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. u2022 Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams. u2022 Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries/complaints, or legal requests. u2022 Assists with reducing rework by identifying and remediating claims processing issues. u2022 Locates and interprets claims-related regulatory and contractual requirements. u2022 Tailors existing reports and/or available data to meet the needs of claims projects. u2022 Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors. u2022 Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational fixes. u2022 Seeks to improve overall claims performance, and ensure claims are processed accurately and timely. u2022 Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance. u2022 Works collaboratively with internal/external stakeholders to define claims requirements. u2022 Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing. u2022 Fields claims questions from the operations team. u2022 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. u2022 Appropriately conveys claims-related information and tailors communication based on targeted audiences. u2022 Provides sufficient claims information to internal operations teams that communicate externally with providers and/or members. u2022 Collaborates with other functional teams on claims-related projects, and completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance. u2022 Supports claims department initiatives to improve overall claims function efficiency. Required Qualifications u2022 At least 3 years of medical claims processing experience, or equivalent combination of relevant education and experience. u2022 Medical claims processing experience across multiple states, markets, and claim types. u2022 Knowledge of claims processing related to inpatient/outpatient facilities contracted with Medicare, Medicaid, and Marketplace government-sponsored programs. u2022 Data research and analysis skills. u2022 Organizational skills and attention to detail. u2022 Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. u2022 Ability to work cross-collaboratively in a highly matrixed organization. u2022 Customer service skills. u2022 Effective verbal and written communication skills. u2022 Microsoft Office suite (including Excel), and applicable software programs proficiency. Preferred Qualifications u2022 Health care claims analysis experience. u2022 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: $21.16 - $46.42 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-12-04