Medicaid Claims Manager

Full Job Description

Are you excited about the challenges and opportunities in large-scale data management? Join the Office of Medicaid Operations within the Utah State Medicaid program as a Medicaid Claims Manager.

This position requires advanced programming experience with SQL and relational databases. Critical thinking is a must as the right answer is not always obvious or known. Having experience with claims processing and data analysis is strongly preferred.

A skills test will be administered to assess skills needed for this position prior to interviews being scheduled.

Why work for the Utah Department of Health and Human Services? In addition to the rich benefits the State of Utah offers, the department offers:

• On-site fitness center, for a minimal membership fee
• UTA Eco Pass, at a discounted monthly rate
• Teleworking opportunities with a minimum 2 office days
• On-site day care center at the Cannon Health Building with First Steps Day Care - contact for rates and availability, 385-382-4012 or firststepschildcareslc@gmail.com

For more information on the Utah Department of Health and Human Services, please click here or Medicaid Operations, please click here.

Requirements

I. Core Data Querying and Analysis

• Develop, write, and execute complex SQL queries, including the use of joins, subqueries, aggregates, and functions, to extract and manipulate data from the Data Warehouse and other relevant systems (e.g., PRISM claims system).

• Extract and prepare data to support various departmental needs, including examining trends, evaluating claims processing, conducting program evaluations, and informing policy development.

• Perform statistical and/or actuarial analysis by applying appropriate protocols to analyze data and draw accurate conclusions.

• Analyze, summarize, and review data to report findings, interpret results, and/or make recommendations for management

II. Data Systems and Troubleshooting

• Act as a subject matter expert and technical resource for management and staff on data availability, structure, and extraction methods.

• Resolve difficult and unusual data problems, leveraging expert knowledge and experience with interfacing automated data systems.

• Review data production for potential issues and propose solutions, enhancements, and procedural changes to improve data quality and efficiency.

III. Reporting and Collaboration

• Write or draft technical reports, articles, or related materials based on in-depth research, investigation, and data analysis.

• Meet and confer with management, end-users, and external contract providers to understand data needs, resolve problems, and coordinate services.

• Ensure all data access and handling practices adhere to strict confidentiality policies, especially when dealing with sensitive information like applicant or recipient data, as mandated by Medicaid/DHHS policy.

Qualifications

Technical Expertise

• Data Engineering Expertise: Proven ability to architect and implement production-ready data solutions and data transformation routines using advanced SQL.

• Analytical Data Modeling: Experience designing and building reliable analytical data models to deliver high-quality, trusted datasets for stakeholders and leadership.

• Legacy System Conversion (EUC Conversion): Skill in reverse-engineering and translating complex business logic from legacy End-User Computing (EUC) tools (such as Microsoft Excel and Access, including VBA macros) into stable, version-controlled code.

• Data Quality & Validation: Experience implementing automated data quality checks, monitoring, and validation processes to ensure solution accuracy and reliability.

Policy and Domain Knowledge

• Regulatory Compliance: Strong understanding of data security principles and experience designing systems that ensure technical compliance with HIPAA, CMS, and state data governance policies when handling Protected Health Information (PHI) and PII.

• Policy Interpretation: Ability to read, interpret, and accurately apply state and federal laws, rules, regulations, and policies related to the Medicaid/Medicare system to inform data solution design.

• Domain Preference: Having experience with healthcare claims processing and data analysis is strongly preferred.

Soft Skills and Work Ethic

• Stakeholder Partnership: Excellent written and verbal communication skills, with the ability to partner with non-technical stakeholders to capture business processes and technical specifications.

• Independent Work: Ability to plan, organize, and prioritize workload, meet deadlines, and work independently to find efficient solutions to technical challenges.

• Critical Thinking: Critical thinking is a must, as the right answer is not always obvious or known

Additional Information

• Risks found in the typical office setting, which is adequately lighted, heated and ventilated, e.g., safe use of office equipment, avoiding trips and falls, observing fire regulations, etc.
• Typically, the employee may sit comfortably to perform the work; however, there may be some walking; standing; bending; carrying light items; driving an automobile, etc. Special physical demands are not required to perform the work.

• Effective July 1, 2021, State of Utah Employees must either reside in Utah or be in the process of relocating to Utah within 30 days of their start date.

• If you are hired and live outside the Wasatch Front, you may report to a local office for your in-office days.

• This position may currently be a hybrid of both in-office and remote work days. Please note, a position's eligibility for remote work is established by agency management and is subject to change at their discretion, at any time, and for any reason.