Mgr, Claims Operations & Research
Molina Healthcare Everett, Washington; Albany, New York; New York; Ohio; Washington; New Mexico; Florida; Michigan; Georgia; Nebraska; Texas; Wisconsin; Kentucky; Iowa; Idaho; Utah; Columbus, Ohio; Savannah, Georgia; Columbus, Georgia; Chandler, Arizona; Albuquerque, New Mexico; Layton, Utah; Orem, Utah; Ann Arbor, Michigan; Detroit, Michigan; Seattle, Washington; Tampa, Florida; Lexington-Fayette, Kentucky; Lincoln, Nebraska; Sioux City, Iowa; Green Bay, Wisconsin; Kenosha, Wisconsin; Caldwell, Idaho; Tucson, Arizona; Salt Lake City, Utah; St. Petersburg, Florida; Rochester, New York; Omaha, Nebraska; Davenport, Iowa; Cincinnati, Ohio; Macon, Georgia; San Antonio, Texas; Fort Worth, Texas; Grand Rapids, Michigan; Jacksonville, Florida; Owensboro, Kentucky; Kearney, Nebraska; Akron, Ohio; Milwaukee, Wisconsin; Meridian, Idaho; Mesa, Arizona; Dallas, Texas; West Valley City, Utah; Sterling Heights, Michigan; Buffalo, New York; Yonkers, New York; New York, New York; Louisville, Kentucky; Grand Island, Nebraska; Rio Rancho, New Mexico; Roswell, New Mexico; Bellevue, Washington; Miami, Florida; Bowling Green, Kentucky; Des Moines, Iowa; Cleveland, Ohio; Atlanta, Georgia; Scottsdale, Arizona; Warren, Michigan; Provo, Utah; Vancouver, Washington; Spokane, Washington; Syracuse, New York; Iowa City, Iowa; Augusta, Georgia; Madison, Wisconsin; Boise, Idaho; Austin, Texas; Houston, Texas; Santa Fe, New Mexico; Covington, Kentucky; Bellevue, Nebraska; Dayton, Ohio; Racine, Wisconsin; Nampa, Idaho; Idaho Falls, Idaho; Phoenix, Arizona; Las Cruces, New Mexico; Tacoma, Washington; Orlando, Florida; Cedar Rapids, Iowa Job ID 2030935JOB DESCRIPTION
Job Summary
Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims\.  Oversees analysis of complex claim inquiries and reimbursement issues using data from internal and external sources to expeditiously resolve claim related concerns. Identifies and interprets trends and patterns in datasets to root cause and resolve outstanding issues. Creates reports and analysis based on business needs and required or available data elements. Collaborates with Health Plans to modify or tailor existing claim analysis reports to meet their specific needs. May participate in external provider meetings, including presenting analysis results, summarizing conclusions, and recommending a course of action. Will work cross functionally across multiple business areas.  Ensures that claims are settled in a timely fashion and in accordance with cost control standards.
KNOWLEDGE/SKILLS/ABILITIES
- Manages and develops a team focused on meeting or exceeding established performance targets. Targets may be based upon plans, federal or state requirements as dictated.
- Proactively plans for daily priorities as well as responds to new priorities within the organization and opportunities assigned from upper management.
- Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.
- Provides oversight of research and analytics associated with medical claims processing requirements (1500 and UB04), provider and benefit configuration, and other claim reimbursement driversÂ
- Responsible for compiling and submitting daily, weekly, and monthly departmental reports to management.
- Acts as a technical expert in handling complaints and other escalated issues from internal and external customers.
- Supports claims performance improvement via participation in special claims initiatives.
- Participates in and support the development of strategies to meet business needs.
JOB QUALIFICATIONS
Required Education
Bachelor's Degree or equivalent combination of education and experience
Required Experience
5-7 years claims processing and/or reimbursement
Preferred Education
Graduate Degree or equivalent combination of education and experience
Preferred Experience
- 7+ years claims processing and/or reimbursement
- Experience using Microsoft Excel
- QNXT experience preferred
- Salesforce experience preferred
Preferred License, Certification, Association
- Certification in Training and Development preferred for manager overseeing Training unit
- Internal Audit Certification a plus for manager overseeing Regulatory Quality Audit unit
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.
Pay Range: $77,969 - $124,371 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 05/06/2025ABOUT OUR LOCATION
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