JOB DESCRIPTION
Job Summary
Support the Nebraska Health plan SLT by providing subject matter expertise on complex claims related issues and service recovery efforts.
Analyzes complex business problems and issues using data from internal and external sources to provide insight to decision-makers. Identifies and interprets trends and patterns in datasets to locate influences. Constructs forecasts, recommendations and strategic/tactical plans based on business data and market knowledge. Creates specifications for reports and analysis based on business needs and required or available data elements. Collaborates with clients to modify or tailor existing analysis or reports to meet their specific needs. May participate in management reviews, including presenting and interpreting analysis results, summarizing conclusions, and recommending a course of action. This is a general role in which employees work with multiple types of business data. May be internal operations-focused or external client-focused.
KNOWLEDGE/SKILLS/ABILITIES
- Elicit requirements using interviews, document analysis, and requirements workshops, business process descriptions, use cases, business analysis, task and workflow analysis.
- Interpret customer business needs and translate them into application and operational requirements
- Communicate and collaborate with external and internal customers to analyze and transform needs, goals and transforming in to functional requirements and delivering the appropriate artifacts as needed.
- Work with operational leaders within the business to provide recommendations on opportunities for process improvements, medical cost savings or revenue enhancements.
- Create Business Requirements Documents, Test Plans, Requirements Traceability Matrix, User Training materials and other related documentations.
- Actively participates in all stages of project and program oversight development including research, design, programming, testing and implementation to ensures the released product meets the intended functional and operational requirements.
- Provide Level II claims support to internal teams and directly with providers as needed
- Monitor and resolve HP work queues related to timely and accurately claims payments and encounters processing.
JOB QUALIFICATIONS
Required Education
Bachelor's Degree or equivalent combination of education and experience
Required Experience
- 5-7 years of business analysis experience with an emphasis in claims payment accuracy and claims service recovery resolutions
- 6+ years managed care experience (preferably in Payer Claims environment)
- Demonstrates proficiency in a variety of concepts, practices, and procedures applicable to job-related subject areas to include Provider Data, Claims Configuration, Claims Adjudication and Encounters.
Preferred Education
Bachelor's Degree or equivalent combination of education and experience
Preferred Experience
- 3-5 years of troubleshooting claims related escalations
- Past direct provider interaction experience
- Experience working with complex, often highly technical teams
- Medicaid primary and Medicare preferable payer claims experience
- QNXT experience
- Coding experience
- SQL experience
- Salesforce experience
Preferred License, Certification, Association
Certified Business Analysis Professional (CBAP)
Certified Professional Coder (CPC) certification
State Specific Requirements:
Experience navigating Nebraska state and Medicare regulations related to claims configuration and payment accuracy.
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.