[Hiring] Senior Claims Operations & Data Analyst @Health Plan of San Joaquin/Mountain Valley Health Plan

Role Description

This is a remote position. Must reside in California, preferably in our service area.

Under limited direction, Claims Operations & Data Analyst, Senior, provides advanced business analysis, workflow redesign, claims data analytics, and system logic support to strengthen Claims Operations. This role integrates responsibilities traditionally split across data analysts and senior business analysts, serving as the department’s expert in:

• Workflow optimization
• Business rule development
• Operational diagnostics
• Claims reporting

The position evaluates operational gaps, redesigns workflows, develops routing logic, produces advanced analytical reporting, and supports alignment of system configuration with business needs. The analyst serves as functional lead for Claims Operations transformation activities, creates executive-level materials, and ensures operational scalability and performance improvements across claims, adjustments, PDR, recovery, QA, and auto-adjust processes. This is a senior independent contributor role with high complexity, broad cross-functional influence, and significant operational impact.

Qualifications

• In-depth knowledge of claims operations, business rules, routing logic, pend logic, adjustments, PDR, QA, recovery, auto-adjust logic, and related workflows.
• Intermediate SQL skills and advanced Excel capabilities.
• Ability to design workflows using Visio/Lucidchart.
• Strong analytical and problem-solving skills.
• Ability to synthesize complex issues and communicate clearly with leadership.
• Ability to influence without authority and act as functional lead for transformation.
• Strong written and verbal communication skills.
• Knowledge of BI tools (Power BI/Tableau preferred).
• Ability to handle confidential information with appropriate discretion.

Requirements

• Bachelor’s Degree; and
• At least five years progressively responsible experience in healthcare claims, business analysis, workflow redesign, or managed care operations; and
• At least three years performing SQL-based analysis; or
• Equivalent combination of education and experience.

• Experience with QNXT (strongly preferred).
• Experience with Jiva.
• Experience creating executive-level materials and operational diagnostics.
• Experience in Medi-Cal claims environments.

Benefits

• Robust and affordable medical coverage including HMO and PPO plan options
• Employee Wellness Program promoting 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, 4 paid floating holidays, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
• Two flexible spending accounts (FSAs) for healthcare and dependent care expenses
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Assistance Program (EAP)
• Health Advocacy to help you navigate medical care and benefits
• Voluntary supplemental benefits including medical, legal, identity theft protection
• Online discount mall
• Tuition reimbursement
• Remote work contingent on business needs and company guidelines
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do

Physical Demands

• Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements.
• Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

• Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

• Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs.
• For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice

The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.