Business Analyst, Senior (Payment Integrity, Claims)

Blue Shield of California • El Dorado, AR

13h • Hybrid

About The Position

Your Role The Payment Integrity team is responsible for ensuring healthcare claims are paid accurately, both in a pre-pay and post-pay context. Some examples of payment integrity include validating coding rules, determining the correct party, membership eligibility, contractual adherence, and conducting root cause analysis to prevent errors. This team is responsible for over $400M+ of cost of healthcare savings and avoidance annually and is also responsible for developing new capabilities to improve cost of healthcare exposure and performance, managing multiple third-party partners in pursuit and prevention of over-payments. The Senior Business Analyst will report to the Director of Payment Integrity. In this role you will collaborate with various internal teams and vendors to improve the cost of healthcare and premium cost outcomes for our Behavioral Health program. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Requirements

• Requires a bachelor’s degree or equivalent experience
• Requires at least 5 years of prior relevant experience
• Knowledge and experience of healthcare claims processing required.
• In depth experience with payment integrity practices and related operations
• Possess strong data/analytic, financial, and process experience

Nice To Haves

• Experience working with behavioral health claims preferred
• Experience with sequel queries and facets claims processing system preferred

Responsibilities

• Provide complex analytical support through the analysis and interpretation of data in support of cross-functional business operation.
• Develop annual operating plans, capital budgets and forecasts, and build business cases for new business initiatives (cost/benefit analysis)
• Develop, prepare, and analyze reports with complex analysis and data for management review, and present to various levels of management.
• Define business requirements and provide analysis to increase operational efficiency.
• Provide analytical support for multiple, complex cross-functional projects simultaneously; establish work plans and timelines.
• Identify novel avenues of pursuit for the improvement of payment accuracy for behavioral health claims.
• Work with internal teams and external vendors on complex initiatives aimed at achieving cost savings and increased effectiveness.
• Validate payment integrity concepts for behavioral health claims through interpretation of provider contracts, review of regulatory guidelines, and system configuration.
• Identify root causes of issues through data analysis and collaborate with other teams to reduce payment errors.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1-10 employees