Claims Operations & Data Analyst, Senior

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, and 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.

Essential Functions:

• Operational & Workflow Analysis

• Conduct end-to-end assessments of Claims Operations workflows, including claims processing, adjustments, PDR, QA, recovery, pend logic, routing, and auto-adjust logic.
• Identify operational gaps, bottlenecks, missed handoffs, and areas requiring process clarification or redesign.
• Redesign workflows, routing rules, and logic models to improve accuracy, efficiency, inventory management, and first-pass outcomes.

• Create detailed workflow maps, decision trees, logic models, and operational documentation.

• Business Rules & System Logic

• Design and recommend updates to business rules, routing criteria, 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.

• Runs auto-adjust process.

• Advanced Claims Data Analysis

• Perform complex SQL queries to analyze claims data, identify trends, assess routing behavior, and evaluate operational outcomes.
• Build advanced Excel models, pivot tables, simulations, and logic-driven tools.

• Develop performance dashboards and claims analytics for leadership.

• Executive-Level Operational Support

• Prepare operational diagnostics, workflow assessments, and cross-functional impact analyses for Director-level and Executive review.
• Summarize complex issues into concise, actionable recommendations.

• Serve as functional lead for transformation initiatives, providing analytical and workflow expertise.

• Transformation & Operational Enablement

• Support inventory governance, operational readiness checks, and workflow standardization.
• Document operational gaps and propose mitigation strategies.
• Partner with leadership to establish sustainable practices and governance structures.

• 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.

What You Have:

Education and Experience

Required

• 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.

Preferred

• Experience with QNXT (strongly preferred).

• Experience with Jiva.

• Experience creating executive-level materials and operational diagnostics.

• Experience in Medi-Cal claims environments., At this time, the Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card, or U.S. citizenship.

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.

• 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, $97,000.00