Claims Policy Analyst II

BlueCross BlueShield of South Carolina•Columbia, SC

3d•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. Description Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-4:30PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located at 17 Technology Circle, Columbia, SC 29203. SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act ( SCA ). To comply with the McNamara-O'Hara Service Contract Act (SCA), employees must enroll in our health insurance even if they have other health insurance. Employees will receive supplemental pay for health insurance until they are enrolled in our health insurance, first of the month following 28 days after the hire date. What You’ll Do: 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.

Requirements

Bachelor's Degree
Equivalency: 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 medical terminology.
Knowledge of Medicare Part B regulations/policies/instructions/provisions.
Working knowledge of Microsoft Excel, PowerPoint, or other spreadsheet/database software.

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.