Claims Policy Analyst II - Palmetto GBA

Palmetto GBA•Columbia, SC

19d•Onsite

About The Position

Interprets all directives and policies to establish processing guidelines for area of expertise. Works with the systems department to create edits/audits and other related changes for the claims system. Maintains and monitors existing edits/audits and requests all maintenance for the claims system. Position requires specific area knowledge and may be seen as the subject matter expert. Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.

Requirements

Bachelor's degree
4 years job related work experience or Associate's and 2 years job related work experience.
3 years of industry specific work experience.
2 years of project administration experience.
Excellent technical skills including knowledge of claims system.
Ability to lead and direct others on assignments.
Skilled at project management.
Ability to persuade, negotiate or influence.
Strong organization, analytical and decision-making skills.
Good personal computer skills.
Thorough understanding of required legislation, guidelines and regulations.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office.

Nice To Haves

Knowledge of Medicare Part B regulations/policies/instructions/provisions.
Knowledge of medical terminology specifically ICD010, HCPCs, and CPT codes is strongly desired.
Working knowledge of Microsoft Excel, PowerPoint, or other spreadsheet/database software.
Expert knowledge in Microsoft Teams working in chats, channels, and documentation storage.

Responsibilities

Reviews, analyzes, researches and interprets all directives and/or claims system update releases.
Identifies all changes needed and prepares and submits claims system maintenance request.
Verifies and approves changes to processing procedures and claims system.
May add codes to the system and verify maintenance and testing.
May serve as liaison between management and less senior staff on management reports, and implementation of documents and mandates.
Approves changes to the on-line claims processing procedure manual and communicate claim processing changes to other areas of relevant operation.
May develop and issue examining memos/help screens and claims processing instructions and provide education on all claims system changes.
Acts as a functional system and claims policy subject matter expert for the area.
Researches and responds to inquiries and/or provider escalations.
Assists the Provider Call Center when subject matter expert is needed to resolve the caller's inquiry.
Assists less senior staff, management and other areas of the operation.
Function as lead for mandates and projects while guiding less senior analysts for departmental management.
Maintains and monitors existing edits/audits and requests maintenance updates as needed.
Analyzes and responds to assigned Claims.
Compiles and reviews monthly/quarterly reports and notifies management of any outstanding issues or problems that could affect critical business processes.
Reviews items for management, identifies discrepancies, gathers explanatory information and makes recommendation on necessary actions or response.
Directs less senior analysts and create action plan to follow protocol to ensure compliance in annual updates.
May build new rules and/or add new codes to the claims system, delete invalid codes from the claims system, and educate the staff on changes.
Assist manager with assignments and special projects.