Lead Business Analyst - Managed Care Operations

Job Summary

Provides lead level support for accurate and timely intake and interpretation of regulatory and/or functional requirements related to coverage, reimbursement, and processing functions to support systems solutions development and maintenance for system changes. This role includes coordination with stakeholders and subject matter experts on partnering teams and supporting governance committees where applicable. This role will work directly with Ohio Healthplan leadership including the Plan President, CFO, and other department heads to improve performance according to our Key Performance Indicators. Candidate will utilize SQL and Azure Databricks to query and analyze data however this is not just a technical role. They must be able to understand the business need, propose solutions, and meet KPIs.

Job Duties

• Develops and maintains requirement documents related to coverage, reimbursement and other applicable system changes in areas to ensure alignment to regulatory baseline requirements and any health plan/product team developed requirements.
• Monitors regulatory sources to ensure all updates are aligned. Uses comprehensive background to navigate analytical problems, including: clearly defining and documenting their unique specifications.
• Leads coordinated development and ongoing management / interpretation review process, committee structure and timing with key partner organizations.
• Recognizes, identifies and documents changes to existing business processes and identifies new opportunities for process developments and improvements.
• Provides status and updates to health plan/product team partners, senior management and stakeholders.
• Communicates requirement interpretations and changes to health plans/product team and various impacted corporate core functional areas for requirement interpretation alignment and approvals as well as solution traceability through regular meetings and other operational process best practices.
• Where applicable, codifies the requirements for system configuration alignment and interpretation.
• Provides support and/or requirement interpretation inconsistencies and complaints.
• Assists with the development of requirement solution standards and best practices while suggesting improvement processes to consistently apply requirements across states and products where possible.
• Self-organized reporting to ensure health plans/product team and other leadership are aware of work efforts and impact for any prospective or retrospective requirement changes that can impact financials.
• Conducts industry research and engagement to evaluate, provide insights, and best practices as applicable.
• Coordinates with relevant teams for analysis, impact and implementation of changes that impact the product.
• Engages with operations leadership and Plan Support functions to review compliance-based issues for benefit planning purposes.
• Mentors and trains new staff as well as provide ongoing support, leadership, and training new/integrating health plans and corporate teams.

Knowledge/Skills/Abilities

Maintains relationships with Health Plans/Product Team and Corporate Operations to ensure all end-to-end business requirements have been documented and interpretation is agreed on and clear for solutioning. Ability to meet aggressive timelines and balance multiple lines of business, states, and requirement areas. Ability to lead complex projects across organizational boundaries with little direct instruction. Strong interpersonal and (oral and written) communication skills and ability to communicate with those in all positions of the company. Ability to concisely synthesize large and complex requirements. Ability to organize and maintain regulatory data including real-time policy changes. Self-motivated and ability to take initiative, identify, communicate, and resolve potential problems. Ability to work independently in a remote environment. Ability to work with those in other time zones than your own. Create reporting tools to enhance communication on updates and initiatives.

Job Qualifications

Required Qualifications
At least 6 years of experience in previous roles in a managed care organization, health insurance or directly adjacent field, or equivalent combination of relevant education and experience. Policy/government legislative review knowledge. Strong analytical and problem-solving skills. Familiarity with administration systems. Robust knowledge of Office Product Suite including Word, Excel, Outlook and Teams. Previous success in a dynamic and autonomous work environment.

Preferred Qualifications
Project implementation experience Knowledge and experience with federal regulatory policy resources including Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act (ACA). Medical Coding certification.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $66,456 - $129,590 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.