Payment Cycle Analyst III

CareSource

About The Position

The Payment Cycle Analyst III is responsible for conducting both systemic and targeted analysis to identify reimbursement errors and to determine root cause. As well as collaborating with Configuration, Configuration UAT, Enterprise UAT, IT Claims, and Payment Cycle Team members to ensure test scripts are comprehensive. Essential Functions: Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members Research and provide recommendations to the Reimbursement Committee for reimbursement of services Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements Identify test result outputs and Claim SOPs that need to be modified or created to support new or changed business requirements Build library of re-usable tests plans & scripts to support the Market Document the status of test results and gaps in testing for future improvements Validate Impact Reports to ensure the criteria is consistent with story and universe of claims impacted by the changes Approve UAT test scripts and test results prior to promoting changes to production and monitor post production results Validate MCA Tests for expected results and communicate information to Reimbursement Analysts and HP Managers for provider notification Conduct both systemic and targeted analysis to identify issues with testing and identify process changes for improvement Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups Perform any other job duties as requested Education and Experience: Bachelor’s degree or equivalent years of relevant work experience is required Minimum of five (5) years of health plan experience is required or equivalent experience with health plan operations and configuration Experience with user testing is required Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) is preferred Competencies, Knowledge and Skills: Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio Strong computer skills and abilities in Facets or equivalent claim payment system is preferred Strong analytical skills with the ability to effectively communicate findings with the Leadership Team Demonstrated understanding of claims operations, configuration, and testing related to managed care Understanding of regression, unit, and user acceptance testing is required Effective listening and critical thinking skills Effective problem-solving skills with attention to detail Creative thinking to develop positive and negative test scenarios Excellent written and verbal communication skills Ability to work independently and within a team environment Strong interpersonal skills and high level of professionalism Ability to develop, prioritize and accomplish goals Understanding of the healthcare field and knowledge of Medicaid, Medicare, and Marketplace Strong working knowledge of claims processing edits and logic Familiar with CMS guidelines / HIPPA and Affordable Care Act Licensure and Certification: None Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation Range: $70,800.00 - $113,200.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-TS1 The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

Requirements

Bachelor’s degree or equivalent years of relevant work experience is required
Minimum of five (5) years of health plan experience is required or equivalent experience with health plan operations and configuration
Experience with user testing is required
Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio
Strong computer skills and abilities in Facets or equivalent claim payment system is preferred
Strong analytical skills with the ability to effectively communicate findings with the Leadership Team
Demonstrated understanding of claims operations, configuration, and testing related to managed care
Understanding of regression, unit, and user acceptance testing is required
Effective listening and critical thinking skills
Effective problem-solving skills with attention to detail
Creative thinking to develop positive and negative test scenarios
Excellent written and verbal communication skills
Ability to work independently and within a team environment
Strong interpersonal skills and high level of professionalism
Ability to develop, prioritize and accomplish goals
Understanding of the healthcare field and knowledge of Medicaid, Medicare, and Marketplace
Strong working knowledge of claims processing edits and logic
Familiar with CMS guidelines / HIPPA and Affordable Care Act

Nice To Haves

Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) is preferred
Strong computer skills and abilities in Facets or equivalent claim payment system is preferred

Responsibilities

Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members
Research and provide recommendations to the Reimbursement Committee for reimbursement of services
Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders
Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties
Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events
Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements
Identify test result outputs and Claim SOPs that need to be modified or created to support new or changed business requirements
Build library of re-usable tests plans & scripts to support the Market
Document the status of test results and gaps in testing for future improvements
Validate Impact Reports to ensure the criteria is consistent with story and universe of claims impacted by the changes
Approve UAT test scripts and test results prior to promoting changes to production and monitor post production results
Validate MCA Tests for expected results and communicate information to Reimbursement Analysts and HP Managers for provider notification
Conduct both systemic and targeted analysis to identify issues with testing and identify process changes for improvement
Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups
Perform any other job duties as requested