Job Description

Job Summary

The Analyst, Reimbursement is responsible for administering complex provider reimbursement methodologies timely and accurately. The analyst will support existing lines of business and expansion into new states.

The Analyst, Reimbursement will be primarily responsible for implementation, maintenance, and support of provider reimbursement for all provider types, including hospitals and facilities priced through PPS pricing methodologies. Works closely with IT, the pricing software vendor, operations, health plan representatives, and other business teams involved in claim processing. Maintains expertise in all forms of reimbursement methodologies including fee for service, value based pricing, capitation, and bundled payments (APG, EAPG, APR-DRG, MS-DRG, etc.). This role is within the Configuration Solution Support team which falls under the Core Operations team for Technical Configuration and Configuration Information Management.

Job Duties

Research, review, and decipher state-specific Medicaid and Medicare reimbursement methodologies for providers, including hospitals and facilities.Developing expertise in complex groupers (APG, EAPG, APR-DRG, MS-DRG, etc.) utilized in reimbursement priced through PPS payment methodologies.Support implementation of new pricers including: Reviewing pricing software vendor specifications.Identifying system changes needed to accommodate state-specific logic.Assisting with requirements development; andCreating and executing comprehensive test plansOngoing pricer maintenance, quality assurance, and compliance with deployment activities.Interpret release notes to accurately request and analyze impact reports of affected claims.Analyzes, interprets, and maintains configurable tables and files that support claim adjudication rules, benefit plan support, and provider reimbursement rules.Assists in the development and execution of testing scenarios and conditions. Performs unit and/or end-user testing for new configuration, programming enhancements, new benefit designs, new provider contracts, and software changes.Analyze and review concerns and pricing variances to validate results, determine root causes drivers, and develop solutions if necessary.Work closely with IT and pricing software vendor to resolve issues.Develop policies and proceduresIdentify automation and improvement opportunities.Research and resolve reimbursement inquiries from internal teams and providers.Other duties as assigned.

Job Qualifications

REQUIRED EDUCATION

Associates Degree or equivalent combination of education and experience

REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES

1 – 2 years’ experience in Managed CareBackground in provider contracts, pricing configuration, claim adjudication or reimbursement processesExperience processing or reviewing facility claimsPrior professional experience utilizing Microsoft Excel (e.g., performing basic data analysis in excel and utilizing pivot tables and various functions such as VLOOKUP)Strong analytical skills to manage complex reimbursement policies and trends.Excellent communication skills to interact with various stakeholders and explain complex reimbursement issues.

PREFERRED EDUCATION

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE

3 – 5 years’ experience in Managed CareExperience researching and resolving provider reimbursement inquiries.Intermediate to Advanced Microsoft Excel skills

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 - $128,519 / 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: Full Time Posting Date: 07/16/2025