Job Description

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.

Duties and 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

Knowledge, Skills and Abilities ( List all knowledge, skills and abilities that are necessary to perform the job satisfactorily)

• 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

Required Education:

Bachelor’s degree in finance, Economics, Computer Science; or combination of relevant education and experience

Required 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

Preferred Experience:

• Multiple data systems and models
  • Complex database and data management responsibilities
  • Claims processing background
  • Configuration background

Preferred Education:

• Bachelor’s Degree in Math or Business

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.