The expected pay range is based on many factors such as geography, experience, education, and the market. This is a remote position. 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. 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. 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. 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. 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 influence without authority and act as functional lead for transformation. • Knowledge of BI tools (Power BI/Tableau preferred). • Ability to handle confidential information with appropriate discretion. Bachelor’s Degree; At least five years progressively responsible experience in healthcare claims, business analysis, workflow redesign, or managed care operations; At least three years performing SQL-based analysis; Experience creating executive-level materials and operational diagnostics. • Experience in Medi-Cal claims environments. 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 At this time, the Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card, or U.Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds. 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. Health Plan of San Joaquin reserves the right to revise this job description at any time.