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