Senior Analyst, Healthcare - Claims Resolution - Remote
Passport Health Plan by Molina Healthcare Lexington-Fayette, Kentucky; Bowling Green, Kentucky; Covington, Kentucky; Louisville, Kentucky; Owensboro, Kentucky Job ID 2032303Passport Health Plan by Molina Healthcare has a mission to provide quality health care to those who need it, no matter their circumstances. Today, Molina health plans serve 3,331,000 members across the country through government-funded programs. Each day, we work to earn the trust our partners and members put in us, so they can lean on Molina. Together, Passport Health Plan and Molina share a commitment to improving the health and quality of life of our members across the Commonwealth of Kentucky.
- Full Time, Part Time
- Level: All Levels
- Travel: Occassional
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Success Profile
What makes you successful at Passport Health Plan by Molina Healthcare? Check out the traits we’re looking for and see if you're the right fit!
- Compassionate
- Consultive
- Patient
- Problem-Solver
- Sincere
- Relationship Expertise
Benefits
-
Insurance
Medical · Dental · Vision
Group & Voluntary Life Insurance
Aflac · Pet Health · Identity Theft
Auto & Home Insurance -
Savings
Flexible Spending Accounts
401K · Roth 401K
Employee Stock Purchase Plan -
Career Growth
Continuing Education Units
Education Reimbursement -
Time Off
Paid Time Off
Volunteer Time Off
Company Holidays -
Additional Perks
Legal Assistance Plan
Employee Assistance & Well Being Programs
Employee Perks Platform
Rideshare Portal
Responsibilities
JOB DESCRIPTION
Job Summary
Performs research and analysis of complex healthcare claims data, pharmacy data, and lab data regarding network utilization and cost containment information. Evaluates, writes, and presents healthcare utilization and cost containment 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.
KNOWLEDGE/SKILLS/ABILITIES
- 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 esclations
- Participate in and support the development of strategies to meet the business needs
- Clarifies and supports organization policies and procedures
- Communicate contract terms, payment structures, and reimbursement rates to physician,hospitals and ancillary providers.
- Implement and use software and systems to support the department’s goals.
- 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
JOB QUALIFICATIONS
Required Education
Bachelor's Degree in Finance, Economics, Computer Science
Required Experience
- 5-7 years increasingly complex database and data management responsibilities
- 5-7 years of increasingly complex experience in quantifying, measuring, and analyzing financial/performance management metrics
- Demonstrate Healthcare experience in Quantifying, Measuring and Analyzing Financial and Utilization Metrics of Healthcare
- Basic knowledge of SQL
- Preferred Education
- Bachelor's Degree in Finance, Economics, Math, or Computer Science
Preferred Experience
- Multiple data systems and models
- Complex database and data management responsibilities
- Claims processing background
- Configuration background
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: $63,133 - $129,589.63 / 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: Posting Date: 07/07/2025ABOUT OUR LOCATION
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