Duties & Responsibilities

• Analyze contract terms, prepare fee schedules and accurately document file changes into the claims processing system

• Research and identify published updates to payment methodologies, fee schedules and claims editing policies from Medicare, Medicaid, and third-party sources.

• Responsible for the overall success of implementations including applicable testing and results verification before sign-off and Production.

• Assist in the on-going audit of configurations for new and existing claims business rules within the claims processing system.

• Identify claims configuration and contract implementation defects and improve departmental performance by supporting quality, operation efficiency and production goals thru reporting.

• Develop and maintain new and existing reporting tools, databases and processes.

• Create and maintain scripts/cases to meet requirements of functional specifications and ensure proper system functionality and quality outcomes including claims configuration, provider set up, reimbursement methodology and core claims system changes.

• Perform training and quality assurance on mass claim adjudications and automated data load processes.

• Query and manipulate claims configuration and claim data to root cause, trend, summarize findings and offer recommendations.

• Work departmentally and interdepartmentally to recommend and implement modifications to existing claims configuration audits and claim reporting functions.

• Review technical specifications to ensure the Claims Configuration Department business requirements are adequately implemented based on technical planning documents.

• Ensure post implementation accuracy of claims configuration implementations and mass claim adjudication projects.

• Recommend changes to address deficiencies and/or further improve and streamline performance based on analysis findings.

• Prepare routine reports as needed (financial, quality, production, operational efficiency, etc.).

• Track and report updates on individual work assignments and other projects within established timeframes

• Assess and prepare to address the operational impacts, workflow, and training issues of the assigned project(s).

• Complete other projects and duties as assigned.

Duties & Responsibilities

• Analyze contract terms, prepare fee schedules and accurately document file changes into the claims processing system

• Research and identify published updates to payment methodologies, fee schedules and claims editing policies from Medicare, Medicaid, and third-party sources.

• Responsible for the overall success of implementations including applicable testing and results verification before sign-off and Production.

• Assist in the on-going audit of configurations for new and existing claims business rules within the claims processing system.

• Identify claims configuration and contract implementation defects and improve departmental performance by supporting quality, operation efficiency and production goals thru reporting.

• Develop and maintain new and existing reporting tools, databases and processes.

• Create and maintain scripts/cases to meet requirements of functional specifications and ensure proper system functionality and quality outcomes including claims configuration, provider set up, reimbursement methodology and core claims system changes.

• Perform training and quality assurance on mass claim adjudications and automated data load processes.

• Query and manipulate claims configuration and claim data to root cause, trend, summarize findings and offer recommendations.

• Work departmentally and interdepartmentally to recommend and implement modifications to existing claims configuration audits and claim reporting functions.

• Review technical specifications to ensure the Claims Configuration Department business requirements are adequately implemented based on technical planning documents.

• Ensure post implementation accuracy of claims configuration implementations and mass claim adjudication projects.

• Recommend changes to address deficiencies and/or further improve and streamline performance based on analysis findings.

• Prepare routine reports as needed (financial, quality, production, operational efficiency, etc.).

• Track and report updates on individual work assignments and other projects within established timeframes

• Assess and prepare to address the operational impacts, workflow, and training issues of the assigned project(s).

• Complete other projects and duties as assigned.

Minimum Qualifications:

• Managed care, commercial health plan (or other healthcare related) experience where you have performed claim or data analysis.

• Experience gathering and communicating business requirements in a simple and easy to understand manner to other staff.

• Experience in Microsoft Excel creating formulas and pivot tables and in using macros and the v-LOOKUP function.

• Experience creating databases and reports using Microsoft Access or other similar database software.

• Experience using report writing tools, i.e. Crystal Reports or SAS.

• Experience creating presentations in Microsoft PowerPoint.

• Experience analyzing data, data mining, managing projects and identifying trends.

• High School Diploma or GED from an accredited institution.

Preferred Qualifications:

• Experience with facility reimbursement methodologies (i.e. Diagnostic Related Groups, DRG; Ambulatory Payment Classification, APC; or Ambulatory Patient Group, APG, etc.).

• Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

• Understanding of payment and billing principles for physician or other professional services (i.e. ancillary, behavioral health, Long Term Care, etc.).

• Experience managing reports in Microsoft Outlook or other communication base systems in order to optimize utilization.

• General understanding of software design and development.

• Ability to communicate clearly in written and verbal form.

• Ability to create effective job aides and review them with key stakeholders at multiple levels of the department and organization.

• Analyze current and potential systems and serve as a resource and subject matter expert (SME) on all aspects of project plan development to support business strategies.

• Assist in the development of process and system efficiency to reduce the number of exceptions and to facilitate or influence change, ultimately improving our competitiveposition and/or optimal performance.

• Ability and willingness to handle increasing workload and responsibility.

• Ability to solve problems under time pressure, with frequent interruptions. Capability of multi-tasking including strong organizational and time management skills.

• Experience with MHS and/or MACESS systems a plus.

• Knowledge of Medicare and Medicaid programs and reimbursement methodologies a plus.

• Knowledge of healthcare claims processing practices in a managed care setting a plus.

• Bachelor's Degree from an accredited institution.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.