Claims Operations & Data Analyst, Senior

SAN JOAQUIN COUNTY HEALTH COMMISSION; Modesto (CA); A distancia; USD 97.000 - 140.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical coverage (HMO/PPO)

Pension plan (CalPERS)

Paid time off (PTO)

Floating holidays

Tuition reimbursement

Remote work contingent on business

Wellness program

Dependent care FSAs

Descripción de la vacante

SAN JOAQUIN COUNTY HEALTH COMMISSION is seeking a senior claims analytics lead to drive advanced analytics, workflow redesign, and system support for Claims Operations. The role emphasizes delivering executive-level materials and scalable processes, with the flexibility to work remotely based on business needs.

You will develop performance dashboards, run complex SQL queries, and build Excel models while partnering with leadership to align rules with QNXT, Jiva, and Symplr Payor.

Formación

• Five+ years in healthcare claims, business analysis, or related operations.
• SQL-based analytics experience (3+ years) and strong Excel skills.
• Experience with QNXT and Jiva is highly preferred.
• Ability to translate complex issues into executive-ready materials.

Responsabilidades

• Provide advanced analysis, workflow redesign, and system logic support.
• Identify bottlenecks and redesign processes to improve outcomes.
• Create workflow maps, decision trees, and operational documentation.
• Develop specifications for configuration improvements and system changes.
• Run SQL queries to analyze claims data, trends, and routing behavior.
• Build dashboards and analytics for leadership review.

Conocimientos

SQL proficiency

Advanced Excel

Workflow design

Leadership

Communication

Influence without authority

Educación

Bachelor’s Degree

Herramientas

Visio

Lucidchart

Power BI

Tableau

QNXT

Jiva

Symplr Payor

Descripción del empleo

SAN JOAQUIN COUNTY HEALTH COMMISSION offers a mission-driven environment focused on improving care for members and the community. This senior role combines advanced claims analytics, workflow redesign, and systems support to strengthen Claims Operations, with the option to work remote contingent on business needs and company guidelines.

You will help drive transformation work as a functional lead, producing executive-level operational materials and performance dashboards while supporting scalable, high-performing claims processes across claims, adjustments, PDR, recovery, QA, and auto-adjust workflows.

What you’ll do

• Provide advanced business analysis, workflow redesign, claims data analytics, and system logic support under limited direction.
• Evaluate operational gaps and redesign workflows, routing logic, and reporting to improve accuracy, efficiency, inventory management, and first-pass outcomes.
• Conduct end-to-end assessments covering claims processing, adjustments, PDR, QA, recovery, pend logic, routing, and auto-adjust logic.
• Identify bottlenecks, missed handoffs, and areas needing process clarification or redesign.
• Create workflow maps, decision trees, logic models, and operational documentation.
• Design and recommend updates to business rules and logic, including assessment logic, pend logic, auto-adjust behavior, and worklist assignment rules.
• Support alignment of operational rules with QNXT, Jiva, Symplr Payor, and related systems.
• Develop specifications for configuration improvements and support readiness for system changes.
• Run auto-adjust process and perform complex SQL queries to analyze claims data, trends, routing behavior, and operational outcomes.
• Build advanced Excel models, pivot tables, simulations, and logic-driven tools.
• Develop performance dashboards and claims analytics for leadership, plus operational diagnostics and cross-functional impact analyses for Director-level and Executive review.
• Summarize complex issues into concise, actionable recommendations and partner with leadership to establish sustainable practices and governance structures.

What you bring

• In-depth knowledge of claims operations and business rules, routing logic, pend logic, adjustments, PDR, QA, recovery, and auto-adjust logic.
• Intermediate SQL skills and advanced Excel capabilities.
• Ability to design workflows using Visio and Lucidchart.
• Strong analytical and problem-solving skills, with the ability to synthesize complex issues and communicate clearly with leadership.
• Ability to influence without authority and act as a functional lead for transformation.
• Strong written and verbal communication skills and discretion with confidential information.
• Knowledge of BI tools (Power BI/Tableau preferred).
• Education: Bachelor’s Degree.
• Experience: At least five years progressively responsible experience in healthcare claims, business analysis, workflow redesign, or managed care operations, including at least three years performing SQL-based analysis (or equivalent combination of education and experience).
• Experience with QNXT (strongly preferred) and Jiva.
• Experience creating executive-level materials and operational diagnostics, including Medi-Cal claims environments.

Compensation

USD 97,000 - 140,000 per year.

Benefits and support

• Robust, affordable medical coverage with HMO and PPO plan options
• Employee Wellness Program supporting physical, mental, and financial well-being
• Dental and vision plan with multiple provider choices
• Generous paid time off: accrue up to 3 weeks of PTO, plus 4 paid floating holidays and 9 paid holidays
• CalPERS retirement pension program with automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
• Two flexible spending accounts (FSAs) for healthcare and dependent care
• Employer-paid Term Life and AD&D Insurance; Employer-paid Disability Insurance
• Employer-Paid Assistance Program (EAP) and Health Advocacy to help navigate medical care and benefits
• Voluntary supplemental benefits including medical, legal, and identity theft protection
• Online discount mall and Tuition reimbursement
• Remote work contingent on business needs and company guidelines

Work setting and demands

• Work may be remote, hybrid, or onsite depending on role requirements and business needs.
• For remote roles, you will maintain a secure, distraction-free workspace and reliable internet connectivity consistent with company standards.
• Physical demands may include frequent sitting, standing, walking, repetitive motion, and frequent talking and listening, with closeup and distance vision requirements.
• Some tasks may require occasional travel and occasional handling of materials up to 50 pounds.
• Emotional/psychological demands may include managing a fast-paced environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, and handling emotional or sensitive situations.

Tools and technologies

• SQL, Excel, Visio, Lucidchart, Power BI, Tableau
• QNXT, Jiva, Symplr Payor
• BI tools