Healthcare Services Analyst II

HMSA•Honolulu, HI

17h

About The Position

This role involves researching and analyzing healthcare inquiries, policies, and claims data to support cost-effective and equitable claims processing. The analyst will be responsible for implementing changes, managing new code implementations, and identifying workflow improvements. This position focuses on low to medium complexity projects and requires collaboration with various departments.

Requirements

Bachelor's degree or equivalent combination of education and work experience.
Two years of related work experience.
Effective verbal, written communication skills.
Excellent organizational and analytical skills.
Working knowledge of medical terminology, anatomy, and health plan benefits.
Good working knowledge of Microsoft Office programs.

Responsibilities

Research and respond to low to medium complexity internal and external inquiries.
Utilize various resources including on-line information files, databases, Medicare/other plan guidelines, plan certificates, and provider contracts.
Make recommendations and decisions independently.
Assess business impact of new benefits, changes in medical or reimbursement policies/guidelines, and tactics assigned in strategic planning.
Initiate, develop, coordinate, and implement cost/benefit analysis of claims processing.
Extract and analyze data using SQL, MicroStrategy, and/or other tools.
Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
Update and create CES pend resolutions.
Drive implementation of changes through writing of Work Intake Form, participation in multi-department meetings, contribution and review of requirements, validation of test cases, and post-implementation monitoring.
Focus on low to medium complexity project implementations.
Act as lead in loading of new codes by following existing documented process and timeline for downloading, processing, and importing new codes (CPT, HCPC, ICD-10, etc.).
Prepare and submit files for review and configuration implementation.
Review new codes in assigned categories, work with Medical Management and Configuration to ensure appropriate claims processing/editing based on new code review.
Support audits of implemented policies and completed projects.
Identify and investigate areas involving cost increases, uncontrolled payments, and/or inequitable payments.
Identification and resolution of issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries.
Develop clear, concise documentation for complex business scenarios to develop policy/project systems and workflow requirements.
Participate in the unit's efforts to implement new projects, software, or software modifications.
Participate in the development of user requirements, test scenarios, and test validation activities.
Attend and successfully complete HMSA and Continuing Education training classes as assigned.
Perform other duties as assigned.