Sr Analyst, Claims Research (Medicaid Claims) Remote

Molina Healthcare is hiring for Senior Analyst, Claims Research. This position is fully remote. Highly Qualified Candidates Will Have the Following Experience – • Experience with medical claims, specifically Medicaid claims • Handling provider claim disputes • Advanced Excel user • QNXT / QNXT Claims (preferred, not required) • Ability to perform root-cause analysis, and resolve issues through system corrections, manual adjustments, or provider education to support claim accuracy • Strong communication skills, both written and verbal Essential Job Duties • Provides senior level analyst support for claims research activities. Ensures timely and accurate resolution of provider submitted claims issues/inquiries. Leverages deep understanding of medical claims processing, analytical skills, root-cause analysis, and regulatory interpretation to effectively triage issues to facilitate complex/high-priority claims investigation or correction. Develops remediation strategies, ensures timely and accurate claims project execution, and drives continuous improvement in claims performance and compliance. • Leverages claims subject matter expertise and advanced analytical skills to conduct research and analysis for provider claims issues, requests, and inquiries, and provide recommendation for remediation and resolution. • Evaluates claims using standard principles and applicable state specific policies and regulations to identify claims processing errors. • Advises on complex claims issues and ensures compliance with regulatory and contractual requirements. • 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. • Assists with reducing re-work by identifying and remediating claims processing issues. • Conducts root-cause analysis to identify and resolve systemic claims processing errors. • Locates and interprets regulatory and contractual requirements to ensure compliance in claims adjudication and remediation processes. • Expertly tailors existing reports or available data to meet the needs of the claims research issue/project. • Applies claims processing and technical knowledge to appropriately define a path for short/long-term systematic or operational claims fixes. • Leads and manages complex claims research projects initiated through provider inquiries, complaints, internal audits, or legal requests. • Develops, tracks, and/or monitors remediation plans, ensuring claims reprocessing projects are completed accurately and on time. • Provides in-depth analysis and insights to leadership and operational teams; presents findings, progress updates, and results in a clear and actionable format. • Takes lead in provider update meetings; clearly communicates findings, proposed solutions, and status updates. • Fields claims questions from the operations team. • Appropriately conveys claims-related information and tailors communication based on targeted audiences • Proactively identifies and recommends updates to policies, standard operating procedures (SOPs), and job aids to improve claims quality and efficiency. • Collaborates with internal/external departments and leadership to define claims requirements and ensure alignment with organizational goals. • Collaborates with multiple departments to define and implement long-term solutions related to claims issues and efficiencies. • Collaborates with cross-functional teams on claims-related projects; completes tasks within designated/accelerated timelines to minimize provider/member impacts and maintain compliance. • Provides training, mentoring and support to new and existing claims research team members. Required Qualifications • At least 3 years of experience in medical claims processing/research and/or health care operations, or 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/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 across a highly matrixed organization. • Experience with process improvement methodologies. • Project management experience. • Effective verbal and written communication skills, and ability to tailor complex information for diverse audiences, including senior leadership and providers. • Microsoft Office suite (including Excel), and applicable software programs proficiency. 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