Analyst, Business
JOB DESCRIPTION
Job Summary
This Business Analyst role interprets regulatory and business requirements and translates them into actionable edit configurations within pre‑pay platforms. This role partners with Payment Integrity, Health Plans, IT, vendors, and SMEs to ensure accurate implementation and optimization of claims editing solutions. The position requires strong ownership, advanced analytical skills, and hands‑on validation of rule‑based logic to ensure alignment with business intent and financial outcomes. It also supports system development, maintenance, and applicable governance activities.
JOB DUTIES
Lead interpretation of state, CMS, and health plan requirements and translate them into business rules, edit logic, configuration strategies, and supporting documentation
Own the full lifecycle of edit development, including requirements intake, configuration, validation, deployment, and ongoing maintenance
Review, validate, and refine rule‑based logic or code to ensure accuracy, completeness, and alignment with regulatory and business intent
Partner with IT, vendors, and cross‑functional teams to ensure successful deployment, issue resolution, and alignment on requirements and solutions
Lead working sessions, governance processes, and interpretation reviews to drive cross‑functional clarity and maintain traceability from requirement to outcome
Monitor regulatory sources and system updates to ensure consistent alignment with coverage, reimbursement, and processing requirements
Perform advanced root‑cause analysis on logic gaps, configuration defects, performance issues, and state‑requirement‑related problems
Communicate requirement interpretations, changes, and impacts to health plans, product teams, and core functional areas
JOB QUALIFICATIONS
Required Qualifications
3+ years of experience in healthcare, managed care, or Payment Integrity, with strong knowledge of claims adjudication, claims editing, reimbursement logic, and related platforms
Proven ability to interpret, review, and validate rule‑based logic or configuration outputs, and synthesize complex requirements into clear business and configuration direction
Strong analytical, problem‑solving, and critical‑thinking skills, including the ability to manage multiple states, lines of business, and aggressive timelines
Effective communicator with experience leading requirement discussions, influencing cross‑functional teams, and organizing regulatory data and real‑time policy updates
Ability to work independently in a remote environment, collaborate across time zones, and utilize Microsoft Office tools (Word, Excel, Outlook, Teams) proficiently
Preferred Qualifications
Familiarity with structured logic, scripting, or rule-based configuration tools
Knowledge and experience with federal regulatory policy resources, including Centers for Medicare & Medicaid Services (CMS), the Affordable Care Act (ACA), and Medicaid state requirements
Experience developing and maintaining requirement documents related to edit configurations
Experience conducting analysis to identify root cause and support problem management related to state requirements
Experience leading UAT, validation cycles, and production deployments
Medical coding knowledge (CPT/HCPCS/ICD) or coding certification
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Summary
This Business Analyst role interprets regulatory and business requirements and translates them into actionable edit configurations within pre‑pay platforms. This role partners with Payment Integrity, Health Plans, IT, vendors, and SMEs to ensure accurate implementation and optimization of claims editing solutions. The position requires strong ownership, advanced analytical skills, and hands‑on validation of rule‑based logic to ensure alignment with business intent and financial outcomes. It also supports system development, maintenance, and applicable governance activities.
JOB DUTIES
Lead interpretation of state, CMS, and health plan requirements and translate them into business rules, edit logic, configuration strategies, and supporting documentation
Own the full lifecycle of edit development, including requirements intake, configuration, validation, deployment, and ongoing maintenance
Review, validate, and refine rule‑based logic or code to ensure accuracy, completeness, and alignment with regulatory and business intent
Partner with IT, vendors, and cross‑functional teams to ensure successful deployment, issue resolution, and alignment on requirements and solutions
Lead working sessions, governance processes, and interpretation reviews to drive cross‑functional clarity and maintain traceability from requirement to outcome
Monitor regulatory sources and system updates to ensure consistent alignment with coverage, reimbursement, and processing requirements
Perform advanced root‑cause analysis on logic gaps, configuration defects, performance issues, and state‑requirement‑related problems
Communicate requirement interpretations, changes, and impacts to health plans, product teams, and core functional areas
JOB QUALIFICATIONS
Required Qualifications
3+ years of experience in healthcare, managed care, or Payment Integrity, with strong knowledge of claims adjudication, claims editing, reimbursement logic, and related platforms
Proven ability to interpret, review, and validate rule‑based logic or configuration outputs, and synthesize complex requirements into clear business and configuration direction
Strong analytical, problem‑solving, and critical‑thinking skills, including the ability to manage multiple states, lines of business, and aggressive timelines
Effective communicator with experience leading requirement discussions, influencing cross‑functional teams, and organizing regulatory data and real‑time policy updates
Ability to work independently in a remote environment, collaborate across time zones, and utilize Microsoft Office tools (Word, Excel, Outlook, Teams) proficiently
Preferred Qualifications
Familiarity with structured logic, scripting, or rule-based configuration tools
Knowledge and experience with federal regulatory policy resources, including Centers for Medicare & Medicaid Services (CMS), the Affordable Care Act (ACA), and Medicaid state requirements
Experience developing and maintaining requirement documents related to edit configurations
Experience conducting analysis to identify root cause and support problem management related to state requirements
Experience leading UAT, validation cycles, and production deployments
Medical coding knowledge (CPT/HCPCS/ICD) or coding certification
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.