Business Analyst- Payment Integrity/Claims & Coding (REMOTE)

Molina Healthcare•Long Beach, CA

1d•Remote

About The Position

This position supports Payment Integrity by researching and developing post-pay recovery concepts and claims edits. The role analyzes healthcare claims, medical billing and coding requirements, and reimbursement policies to identify potential overpayment opportunities and translate findings into clearly defined business requirements for technical implementation. The Business Analyst researches and interprets applicable CMS, NCCI, state Medicaid, Medicare, and other reimbursement and coding guidance to support defensible claims-recovery logic. The role also documents claim logic, coding criteria, inclusions, exclusions, and supporting information for analytic and technical development teams.

Requirements

At least 2 years of experience in previous roles in a managed care organization, health insurance, or a directly adjacent field, or an equivalent combination of relevant education and experience.
Knowledge of policy and government legislative review.
Strong analytical and problem-solving skills.
Robust knowledge of Microsoft Office products, including Word, Excel, Outlook, and Teams.
Previous success in a dynamic and autonomous work environment.
Working knowledge of healthcare claims, medical billing, reimbursement methodologies, and coding systems including CPT, HCPCS, ICD-10, revenue codes, modifiers, and claim types.
Ability to research reimbursement and coding policies and translate policy requirements into actionable claims logic and business requirements.
Ability to analyze claims data to identify billing patterns, potential overpayments, and Payment Integrity recovery opportunities.

Nice To Haves

Experience working with healthcare claims, medical billing or coding, reimbursement, Payment Integrity, claims auditing, or an equivalent claims-focused function.
Payment Integrity or post-pay claims recovery experience.
Experience developing or supporting claims edits, payment policies, recovery concepts, or reimbursement rules.
Experience with CMS, NCCI, Medicare, Medicaid, and/or state-specific reimbursement guidance.
Medical coding certification such as CPC, CCS, COC, or equivalent.

Responsibilities

Research and develop post-pay Payment Integrity recovery concepts and claims edits by evaluating healthcare claims, reimbursement patterns, medical billing and coding requirements, and applicable regulatory and payer guidance.
Research and interpret CMS, NCCI, state Medicaid, Medicare, and other applicable reimbursement and coding requirements to support defensible claims-recovery logic.
Translate Payment Integrity opportunities into detailed business requirements, including claim logic, coding criteria, inclusions, exclusions, and supporting documentation for analytic and technical development teams.
Analyze claims data to identify billing patterns, potential overpayments, and Payment Integrity recovery opportunities.