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 fully remote role focuses on timely and accurate resolution of provider-submitted claims issues and inquiries. The analyst uses medical claims expertise, analytical skills, root-cause analysis, and regulatory interpretation to investigate and correct complex or high-priority claims issues, develop remediation strategies, and support continuous improvement in claims performance and compliance. The position researches provider claims issues, evaluates claims against standard principles and state-specific policies and regulations, advises on complex claims, and ensures compliance with regulatory and contractual requirements. The analyst develops and monitors remediation plans and claims reprocessing projects, interprets and presents findings and progress to leadership, operational teams, and providers, and helps define systematic or operational fixes. The role also collaborates across departments, recommends improvements to policies and procedures, responds to operations-team questions, and trains and mentors 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 in claims management systems and data analysis and 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 such as senior leadership and providers.
Proficiency with Microsoft Office, including Excel, and applicable software programs.
Experience with medical claims, specifically Medicaid claims.
Experience handling provider claim disputes.
Advanced Excel skills.
Ability to perform root-cause analysis and resolve issues through system corrections, manual adjustments, or provider education to support claim accuracy.
Strong written and verbal communication skills.

Nice To Haves

Experience with QNXT or QNXT Claims; preferred but not required.

Responsibilities

Provide senior-level analyst support for claims research activities and resolve provider-submitted claims issues and inquiries accurately and on time.
Triage and investigate complex or high-priority claims issues using claims-processing knowledge, analysis, root-cause analysis, and regulatory interpretation.
Develop remediation strategies and support accurate, timely claims project execution and continuous improvement in claims performance and compliance.
Research provider claims issues, requests, and inquiries and 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 the 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 meet claims research needs.
Define short- and long-term systematic or operational claims fixes using claims-processing and technical knowledge.
Lead and manage complex claims research projects initiated through provider inquiries, complaints, internal audits, or legal requests.
Develop, track, and monitor remediation plans and ensure claims reprocessing projects are accurate and completed on time.
Provide analysis and insights to leadership and operational teams and present findings, progress, and results clearly and actionably.
Lead provider update meetings and communicate findings, proposed solutions, and status updates.
Field 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, leadership, and cross-functional teams to define claims requirements, align with organizational goals, and implement long-term solutions.
Complete cross-functional claims project tasks within designated or accelerated timelines to minimize provider and member impacts and maintain compliance.
Train, mentor, and support new and existing claims research team members.