Sr Analyst, Claims Research (Medicaid Claims) Remote

Molina Healthcare•Long Beach, CA

4d•Remote

About The Position

Molina Healthcare is hiring a Senior Analyst, Claims Research to provide senior-level support for claims research activities. This position is fully remote and focuses on timely, accurate resolution of provider-submitted claims issues and inquiries, with particular emphasis on medical and Medicaid claims. The analyst uses claims-processing expertise, analytical skills, root-cause analysis, and regulatory interpretation to investigate complex or high-priority issues and determine appropriate remediation. The role evaluates claims against standard principles and applicable state-specific policies and regulations, advises on complex claims matters, and ensures compliance with regulatory and contractual requirements. It also develops remediation strategies, manages claims research projects and reprocessing efforts, and recommends systematic or operational fixes to improve claims accuracy, performance, and compliance. The analyst communicates findings, root causes, remediation plans, progress, and status to providers, operational teams, and leadership. The role collaborates across departments, supports continuous improvement of policies and procedures, and provides training and mentoring to claims research team members.

Requirements

At least 3 years of experience in medical claims processing or research and/or health care operations, or an equivalent combination of relevant education and experience.
Strong medical claims-processing experience across multiple states, markets, and claim types.
Advanced experience with Medicaid, Medicare, and Marketplace claims.
Advanced knowledge of medical billing codes and claims adjudication processes.
Advanced proficiency with claims management systems and data analysis or research tools.
Expertise in regulatory and contractual claims requirements and root-cause analysis.
Strong 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.
Strong customer service skills.
Strong analytical and problem-solving skills.
Ability to work independently and as part of a team, and collaborate cross-functionally in a highly matrixed organization.
Experience with process improvement methodologies.
Project management experience.
Effective verbal and written communication skills, including the ability to tailor complex information for diverse audiences, including senior leadership and providers.
Proficiency with Microsoft Office, including Excel, and applicable software programs.
Strong communication skills, both written and verbal.

Nice To Haves

QNXT or QNXT Claims experience is preferred but not required.

Responsibilities

Provide senior-level analyst support for claims research activities.
Ensure timely and accurate resolution of provider-submitted claims issues and inquiries.
Triage issues and facilitate complex or high-priority claims investigations and corrections using claims-processing knowledge, analysis, root-cause analysis, and regulatory interpretation.
Develop remediation strategies and ensure timely, accurate execution of claims projects.
Research and analyze provider claims issues, requests, and inquiries; recommend remediation and resolution.
Evaluate claims using standard principles and applicable state-specific policies and regulations to identify processing errors.
Advise on complex claims issues and ensure compliance with regulatory and contractual requirements.
Interpret and communicate claims research results, root-cause analyses, remediation plans, fixes, progress, and status of impacted claims.
Identify and remediate claims-processing issues to reduce rework, including systemic errors.
Locate and interpret regulatory and contractual requirements relevant to claims adjudication and remediation.
Tailor existing reports or available data to address claims research issues and projects.
Define short- and long-term systematic or operational claims fixes using claims-processing and technical knowledge.
Lead and manage complex claims research projects arising from provider inquiries, complaints, internal audits, or legal requests.
Develop, track, and monitor remediation plans and ensure claims reprocessing projects are completed accurately and on time.
Provide analysis and insights to leadership and operational teams, and present findings, progress, and results clearly.
Lead provider update meetings and communicate findings, proposed solutions, and status updates.
Answer claims questions from the operations team and tailor claims-related communications to the audience.
Recommend updates to policies, standard operating procedures, and job aids to improve claims quality and efficiency.
Collaborate with internal and external departments and leadership to define claims requirements and align with organizational goals.
Work with multiple departments and cross-functional teams to implement long-term solutions and complete claims-related project tasks within designated or accelerated timelines.
Train, mentor, and support new and existing claims research team members.