Business Rule Management Analyst

Community Behavioral Health.•Philadelphia, PA

10d•$0 - $67,500

About The Position

The Business Rule Management Analyst is responsible for ensuring the accurate, timely, and compliant submission of encounter data to the State. This position performs ongoing monitoring, analysis, and resolution of encounter errors and works collaboratively with Claims, IT, Business Owners, and other stakeholders to identify root causes and implement solutions that support successful encounter submissions. The position is also responsible for maintaining and updating the claims adjudication system to ensure approved business rules are accurately configured and applied. The Analyst works closely with CBH Business Owners to understand business requirements, translate those requirements into system functionality, and ensure claims are adjudicated in accordance with CBH policies, contractual requirements, and established business rules.

Requirements

Associate’s degree required
At least 3 years of experience in Claims or Behavioral Health
Proficient in Excel and Word
Thorough understanding and knowledge of claims submission requirements
Strong problem solving and analysis skills
Detail-oriented and accurate data entry skills
Strong organizational skills
Ability to multi-task in fast paced environment
Sound judgment and decision making skills
Excellent customer service attitude
Strong teamwork, communication and interpersonal skills
Knowledge of HIPAA EDI 5010 ASC X12 837P, 837I, 835, 277CA, TA1 and 999 transaction sets
Must be a current Philadelphia resident or become a resident within six months of hire.
Must be legally authorized to work in the United States without requiring sponsorship now or in the future.

Nice To Haves

Bachelor’s degree preferred

Responsibilities

Monitor encounter submissions to ensure data is accurate, complete, timely, and compliant with State requirements.
Review State encounter response files, including rejections, errors, and other exceptions, to identify trends and recurring issues.
Analyze encounter errors and perform root-cause analysis to determine the source of discrepancies.
Develop, document, and implement appropriate resolutions to ensure encounters are successfully submitted and accepted by the State. Complete testing to ensure resolution is valid.
Coordinate with Claims, IT, Business Owners, and other departments to resolve encounter-related issues.
Monitor encounter correction and resubmission activities through successful State acceptance.
Maintain documentation of encounter issues, resolutions, system changes, and corrective actions via JIRA.
Identify opportunities to improve encounter processes, reduce errors, and increase the efficiency and accuracy of State submissions.
Support State audits, inquiries, and requests related to claims.
Validate encounter-related system changes to ensure they produce the expected results prior to implementation.
Work with CBH Business Owners to identify, define, and document business requirements affecting claims adjudication.
Translate approved business requirements into system business rules and configuration requirements.
Ensure claims are adjudicated in accordance with CBH Business Owner requirements, policies, contractual obligations, and approved system specifications.
Analyze existing business rules to determine the impact of requested changes on claims processing, encounters, providers, members, and other downstream processes.
Participate in requirements gathering, business rule development, testing, implementation, and post-implementation validation.
Conduct testing of new or modified business rules and document test results.
Identify unintended impacts or conflicts between existing and proposed business rules and coordinate resolution with appropriate stakeholders.
Maintain accurate documentation of business rules, system configurations, testing, approvals, and implementation dates.
Participate in change control and SDLC activities associated with claims system modifications.
Ensure system changes are appropriately reviewed, approved, documented, and implemented in accordance with CBH processes.
Analyze claims and encounter data to identify trends, anomalies, processing issues, and opportunities for improvement.
Investigate discrepancies between claims adjudication results and encounter data submitted to the State.
Recommend process and system improvements based on data analysis and identified operational issues.
Maintain knowledge of State encounter requirements, CBH policies, claims processing requirements, and applicable business rules.
Serve as a subject matter resource for business rules, claims adjudication, and encounter submission processes.