Business Analyst- Medicaid Overpayment Recovery

Job Description

JOB DESCRIPTION

Job Summary

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

Duties and Responsibilities (List all essential duties and responsibilities in order of importance)

• Analyze overpayment data to identify opportunities for improvement in financial recovery processes and mitigating the root causes of overpayments.
• Analyze data to identify and develop new recovery opportunities
• Analyze data from Payment Integrity and Vendors against contracts, billing, and processing guidelines
• Analyze data sets and trends for anomalies, outliers, trend changes, and opportunities to recommend policy changes
• Analytical mindset- having the ability to consider relevant facts and contextual information, in order to make informed decisions or implement rational solutions
• Conduct peer reviews of recovery concepts and offer recommendations for logical improvements; assist team members in their analysis of data sets and trends.
• Conduct in-depth analysis of the suspect/problem areas and suggest a corrective action plan for future prevention and issue resolution.
• Collaborate and work cross-functionally with other operational areas (Claims, Provider Network Management, Contract Configuration, Provider File Operations, Payment Integrity, etc.) to ensure causes of overpayments are understood and root causes are ultimately remediated.
• Apply investigative skills and analytical methods to look behind the numbers, assess business impacts, and make recommendations through use of healthcare analytics, predictive modeling, etc.
• Interact with various departments including IT, Contracting, Corporate Services, Claims, Utilization Management and Payment Integrity to understand claim related policies and payment processes, member benefits, contracts and State requirements
• Responsible for documenting policies and procedures related to concept approvals
• Participate in and support the development of strategies to meet the business needs
• Implement and use software and systems to support the department’s goals.
• Conduct trainings and prepare training documentation for team
• Thoroughly investigate all possible third-party liability cases (Commercial/Medicare Insurance, Workers Comp Motor Vehicle Insurance) that are referred by Claims Staff, Billing and Enrollment, Member Services, Provider Services, Reports or Mass Mailing Questionnaires.
• Other duties as assigned State Plan / Department Specific Duties and Responsibilities (List all essential duties other than those listed above in order of importance)
• Ability to practice Service Excellence (Molina Kentucky)

Knowledge, Skills and Abilities (List all knowledge, skills and abilities that are necessary to perform the job satisfactorily)

• Ability to manage various sources of information and large data sets including claims and encounter data
• Proficiency in compiling data, creating reports and presenting information, including knowledge of SQL query, MS Access, Power BI 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 independently perform research utilizing multiple sources
• Ability to develop scenario analysis using different approaches
• Strong analytical and problem-solving skills
• Ability to present ideas and information concisely to varied audiences
• Strong auditing skills that be applied across all types of business problems
• Apply process improvements for the team's methods of collecting and documenting report / programming requirements from requestors to ensure appropriate creation of reports and analyses while reducing rework.
• Manage the creation of comprehensive workflows for the production and distribution of assigned reports, document reporting processes and procedures.
• Create comprehensive workflows for the production and distribution of assigned reports, document reporting processes and procedures.
• 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
• 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

NON-ESSENTIAL FUNCTIONS

List other duties which are of secondary importance and marginal to the position’s purpose.

• Provide hosting services to external personnel visiting the health plan
• Other duties as assigned.

QUALIFICATIONS

Required Education:

Bachelor's Degree or equivalent combination of education and experience. Preferred Education: Bachelor's Degree or equivalent combination of education and experience.

Required Experience:

• 5-7 years of business analysis experience
• 6 years Manage Care experience.
• Demonstrates proficiency in a variety of concepts, practices, and procedures applicable to job-related subject areas.

Preferred Experience: · Multiple data systems and models · Claims processing background · Complex database and data management responsibilities · Cost Containment background · Medicaid background · Medical Coding background · Basic knowledge of SQL

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.

Job Info

Job Identification: 2030443

Job Category: Cross-Enterprise Roles

Posting Date: 2025-03-28T17:01:23 00:00

Job Schedule: Full time