Business Analyst- Payment Integrity/Claims & Coding (REMOTE)

Responsibilities

This role supports payment integrity by researching and developing post-pay recovery concepts and claims edits. The analyst translates these findings into detailed business requirements for technical implementation teams.

Requirements

Candidates must have at least 2 years of experience in managed care or health insurance with strong analytical and problem-solving skills. Proficiency in medical coding and reimbursement methodologies is required, with professional certifications preferred.

Skills

• Healthcare claims
• Medical billing
• Coding systems
• CPT
• HCPCS
• ICD-10
• Payment integrity
• Claims auditing
• Data analysis
• Business requirements
• CMS
• NCCI
• Medicare
• Medicaid
• Reimbursement policies
• Problem-solving

Benefits

• Competitive benefits package

About this role

JOB DESCRIPTION

Job Summary

This position supports Payment Integrity through the research and development of
post-pay recovery concepts and claims edits. The role analyzes healthcare
claims, medical billing and coding requirements, and reimbursement policies to
identify potential overpayment opportunities and translate findings into clearly
defined business requirements for technical implementation. 

JOB DUTIES

* Researches and develops post-pay Payment Integrity recovery concepts and
claims edits by evaluating healthcare claims, reimbursement patterns, medical
billing and coding requirements, and applicable regulatory and payer
guidance.
* Researches and interprets CMS, NCCI, state Medicaid, Medicare, and other
applicable reimbursement and coding requirements to support development of
defensible claims-recovery logic.
* Translates identified Payment Integrity opportunities into detailed business
requirements, including claim logic, coding criteria, inclusions, exclusions,
and supporting documentation for analytic and technical development teams.

KNOWLEDGE/SKILLS/ABILITIES

* Working knowledge of healthcare claims, medical billing, reimbursement
methodologies, and coding systems including CPT, HCPCS, ICD-10, revenue
codes, modifiers, and claim types.
* Ability to research reimbursement and coding policies and translate policy
requirements into actionable claims logic and business requirements.
* Ability to analyze claims data to identify billing patterns, potential
overpayments, and opportunities for Payment Integrity recovery concepts.

JOB QUALIFICATIONS

Required Qualifications

* At least 2 years of experience in previous roles in a managed care
organization, health insurance or directly adjacent field, or equivalent
combination of relevant education and experience.  
* Policy/government legislative review knowledge.
* Strong analytical and problem-solving skills.
* Robust knowledge of Office Product Suite including Word, Excel, Outlook and
Teams.
* Previous success in a dynamic and autonomous work environment.

Preferred Qualifications

* Experience working with healthcare claims, medical billing/coding,
reimbursement, payment integrity, claims auditing, or an equivalent
claims-focused function.
* Payment Integrity or post-pay claims recovery experience.
* Experience developing or supporting claims edits, payment policies, recovery
concepts, or reimbursement rules.
* Experience with CMS, NCCI, Medicare, Medicaid, and/or state-specific
reimbursement guidance.
* Medical coding certification such as CPC, CCS, COC, or equivalent.

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.

About Molina Healthcare

Hospitals and Health Care · 10,001+ employees · headquartered in Long Beach, California