Mgr, Claims Operations & Research

Molina Healthcare
US - Iowa - Des Moines
May 9, 2025

JOB 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 drivers

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.

Read the full job description and apply online on the recuiter's web-site

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