Claims Business Analyst

Partnership HealthPlan of California•Fairfield, CA

15d•$37 - $47

About The Position

Overview To design, produce, and analyze Claims Department operational data in support of department objectives and goals. To provide organizational and technical support for the analysis, design, configuration, and documentation of Partnership’s computer systems, and technical and problem resolution support to the systems user community. Utilize knowledge of numerous applications, databases, information systems, statistical tools and analytical principles to monitor and analyze information related to department operations. Responsibilities Creates and runs all reports that are required from retro system configuration updates to identify all impacted claims for Recovery of monies or for adjustments to previously paid claims Serve as a liaison for Claims to Configuration, Contracting, and Finance. Maintains in-depth knowledge of Partnership systems from a technical and end-user perspective. Performs analysis, design, configuration, and testing of assigned systems. Uses various resources to troubleshoot and resolve system issues. Tests and takes part in implementation of new releases and upgrades. Analyzes new systems and functionality and makes recommendations to business users and IT. Writes processes and procedures. Track all recovered monies through the claims process Creates and runs all reports that need to be ran to identify provider trends Performs system audits to ensure the system is behaving as expected Performs internal audits of all Partnership Provider contracts 90 days post implementation Run ad hoc reports as requested Prepares monthly summary of System audits Prepares quarterly summary of Contract audits Monitor health plan policies and procedures and assist with documenting Claims related business requirements and decisions that result from configuration and other change driven sources. Participates in system upgrade/update testing as needed Develops short and/or long-term resolutions by identifying root causes using reporting and other data files available Troubleshoot and perform research on medium to moderately complex claims processing issues and projects. Provide recommendations on the design of claim payment system configuration Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support Maintain regular and consistent contact with operations management, clinical leadership, and appropriate health plan leaders Analyze, interpret, and recommend updates to policy and procedures applicable to managed care reimbursement payment methodologies using payment rules and requirements from sources such as CMS, California State Medi-Cal, and DHCS. Other duties as assigned.

Requirements

Associates degree in related field preferred; Minimum of two years healthcare experience, preferably in managed care environment; or equivalent experience and training that would provide the knowledge and acquired skills and abilities listed above.
Demonstrates aptitude for acquiring new technical skills in data reporting and database support.
Detail-oriented with strong organizational skills.
Excellent written and oral communication skills.
Ability to work on multiple assignments, prioritize work, and meet established timelines.
Ability to use a PC with standard software packages and a 10 key calculator.
When required, ability to move, care, and/or lift objects of varying sizes weighing up to 25 lbs.
Must be able to operate a car for company business.
All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

Nice To Haves

Experience with Health Rules Payer, or similar claims payment system, and knowledge of Business Intelligence or similar reporting software preferred.

Responsibilities

Creates and runs all reports that are required from retro system configuration updates to identify all impacted claims for Recovery of monies or for adjustments to previously paid claims
Serve as a liaison for Claims to Configuration, Contracting, and Finance.
Maintains in-depth knowledge of Partnership systems from a technical and end-user perspective.
Performs analysis, design, configuration, and testing of assigned systems.
Uses various resources to troubleshoot and resolve system issues.
Tests and takes part in implementation of new releases and upgrades.
Analyzes new systems and functionality and makes recommendations to business users and IT.
Writes processes and procedures.
Track all recovered monies through the claims process
Creates and runs all reports that need to be ran to identify provider trends
Performs system audits to ensure the system is behaving as expected
Performs internal audits of all Partnership Provider contracts 90 days post implementation
Run ad hoc reports as requested
Prepares monthly summary of System audits
Prepares quarterly summary of Contract audits
Monitor health plan policies and procedures and assist with documenting Claims related business requirements and decisions that result from configuration and other change driven sources.
Participates in system upgrade/update testing as needed
Develops short and/or long-term resolutions by identifying root causes using reporting and other data files available
Troubleshoot and perform research on medium to moderately complex claims processing issues and projects.
Provide recommendations on the design of claim payment system configuration
Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support
Maintain regular and consistent contact with operations management, clinical leadership, and appropriate health plan leaders
Analyze, interpret, and recommend updates to policy and procedures applicable to managed care reimbursement payment methodologies using payment rules and requirements from sources such as CMS, California State Medi-Cal, and DHCS.
Other duties as assigned.