Senior Analyst, Healthcare Claims Resolution

Molina Healthcare•Long Beach, CA

About The Position

Performs research and analysis of complex healthcare claims data, pharmacy data, and contract data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and operations reports and makes recommendations based on relevant findings. This position is responsible for proactively identifying claim issues, resolving disputes, and coordinating solutions while overseeing and managing the activities of assigned providers from initiation to completion of the program. This role contributes to the strategic direction and organization of health plan initiatives, facilitating the successful implementation of provider engagement programs.

Requirements

Strong knowledge of provider data/processes/requirements related to provider contracting, credentialing, claims processing and state/federal regulations
Ability to interpret, communicate, and suggest revisions to core claims operation and data configuration SOP’s, BRDs, and/or guidelines as needed
Identify and implement continuous improvement opportunities as needed
Ability to manage various sources of information and large data sets including pharmacy, claims and encounter data
Proficiency in compiling data, creating reports and presenting information, including knowledge of Power BI Reports (or similar reporting tool), SQL query, MS Access and MS Excel
Ability to combine clinical and financial data
Demonstrated ability to meet established deadlines
Ability to function independently and manage multiple projects
Ability to develop scenario analysis using different approaches
Ability to present ideas and information concisely to varied audiences
Proficiency with PC-based systems, and the ability to learn other systems through knowledge of MS Excel and Access
Excellent verbal and written communication skills
Ability to quickly assimilate knowledge of processes and systems to develop and deliver necessary training to departmental staff and internal customers
Ability to work in a deadline driven department
Bachelor’s degree in finance, Economics, Computer Science; or combination of relevant education and experience
4-6 years’ experience in a Managed Care Environment
5-7 years of increasingly complex database and data management responsibilities
Claims processing background
Basic knowledge of SQL

Nice To Haves

Multiple data systems and models
Complex database and data management responsibilities
Claims processing background
Configuration background
Bachelor’s Degree in Math or Business

Responsibilities

Analyze claims from compliance against contracts, billing, and processing guidelines
Assist with research, development and completion of special projects as requested by various internal departments, or in support of requests from regulatory agencies, contracting agencies, or other external organizations.
Responsible for timely completion of projects, including timeline development and maintenance, and coordination of activities and data collection with requesting internal departments or external requestors.
Initiate in-depth analysis of the suspect/problem areas and suggest a corrective action plan
Collaborates with internal departments to determine root cause and analytical approach to payment discrepancies.
Apply investigative skills and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modleing, etc.
Interact with various departments including; IT, Contracting, Corporate Services, Claims, Utilization Management. Configuration and Payment Integrity to understand claim-related policies and payment processes, member benefits, contracts and State requirements
Responsible for documenting job aids, billing guidelines, policies and procedures related to operations
Responsible for the submission, research, and resolution of provider inquiries and/or escalations
Participate in and support the development of strategies to meet business needs
Clarifies and supports organization policies and procedures
Communicate contract terms, payment structures, and reimbursement rates to physicians, hospitals and ancillary providers.
Implement and use software and systems to support the department’s goals.
Other duties as assigned