Lead Regulatory Claims Analyst

Molina Healthcare; United States; On-site; USD 60,000 - 130,000; Full time

Job summary

Molina Healthcare in the United States seeks a professional who interprets regulatory requirements related to coverage, reimbursement, and claims processing, translating them into documented system configuration requirements and partnering with stakeholders and governance committees.

The role develops requirements documentation, monitors regulatory updates, coordinates reviews with health plans, communicates decisions, and provides reporting on status, trends, and potential financial impacts for

Qualifications

• 5+ years of core system management or analyst experience in managed care operations.
• Advanced experience with claims processing systems and validation.
• Strong analytical and attention to detail.
• Excellent written and verbal communication.
• Proficiency with Microsoft Office, especially Excel.
• Familiarity with QNXT and Networx Pricer.

Responsibilities

• Interprets state, federal, contractual, benefit, and business requirements into clear configuration parameters.
• Develops and maintains requirements documentation for coverage, reimbursement, claims processing, and related configuration requirements.
• Monitors regulatory/industry updates to identify impacts to products, payments, and compliance.
• Coordinates benefit interpretation reviews and implementation timelines with health plans and partners.
• Communicates decisions and changes to stakeholders with end-to-end documentation and traceability.

Skills

Core system management

Database maintenance

Claims processing systems

Advanced Excel (VLOOKUP, PivotTables)

Regulatory compliance

Tools

QNXT

Networx Pricer

Job description

Molina Healthcare in the United States seeks a professional who interprets regulatory requirements related to coverage, reimbursement, and claims processing, translating them into documented system configuration requirements and partnering with stakeholders and governance committees.

The role develops requirements documentation, monitors regulatory updates, coordinates reviews with health plans, communicates decisions, and provides reporting on status, trends, and potential financial impacts for