The Payment Integrity Claims Editing Analysis functions to provide analytical, technical, and problem resolution support to Payment Integrity Claims Editing System. Candidate must use knowledge of existing business practices, systems, procedures, policies, current testing tools/practices and their interrelationships to provide and ensure innovative approaches and solutions to business problems and requirements in the supported systems. The analyst is responsible for obtaining necessary approvals on systems configuration, systems testing and application changes.

Work with internal and external partners to identify and validate new provider concepts and scenarios through analysis of paid claims data, review of internal payment and medical policies, and any other pertinent information to support determination(s). Independently evaluate and analyze submitted claims to ensure the concepts/scenarios aligns with Capital book of business. Includes but not limited to:

• Research and analysis of applicable provider contract terms and rates
• Analysis of member benefits and utilization
• Analysis of overarching administrative regulations (Federal, State, BCBSA, etc.)
• Analysis of appropriate provider coding and billing practices and coding guidelines.

Serve as a department lead for to present new edit concepts and issues to internal business areas. Communicate status updates verbally and in writing to impacted internal business areas. Identify new edit or solutions, projects risks, and contingencies. Conduct root cause analysis and identify process improvement opportunities. Build strong working relationships with internal and external customers. Summarize verbally and in writing, advanced analytical research, including claim analysis, which is understandable to the intended audience. Facilitate meetings including preparing agendas, minutes, and other documentation as needed. Communicate delays, risks, and impacts to both management and business areas.

 

Ongoing business evaluation of vendor updates, but not limited to LCD reviews, and knowledge base updates (edits). Elicit and document detailed business requirements to support maintenance activities, tasks, and other duties as assigned. 

 

Anticipate problems before they occur, document options for solutions, seek necessary approvals, and work with business areas to implement solutions and track progress. Generate and consider options to achieve a long-range goals or visions to meet business needs.

 

Work with Payment Integrity staff as a “coach” to promote staff learning regarding the CES process and impact to their activities. Respond to questions from internal and external customers. Develop and/or maintain departmental processes and procedures.

 

Leadership:

• Ability to lead meetings and give presentations to both management and staff. Includes the ability to develop teamwork among diverse groups.
• Serve as a Claims Editing SME for targeted system applications & technical knowledge (i.e., Facets & CES)

Skills: 

• Technical understanding of Microsoft Office Suite, Crystal Reporting, SharePoint, Pareo, Facets Data Modeling and the Claims Editing System (CES). Ability to analyze data, determine impact, and develop business solutions for system changes. Ability to function as a liaison by analyzing and recommending multiple solutions cross-functionally, as well as other external business partners.
• Ability to plan, organize, prioritize, lead and control multiple projects & tasks simultaneously. 
• Ability to effectively communicate in writing and verbally with technical and non-technical audiences. Also includes persuasion and negotiation skills to resolve differences with skill and understanding.
• Ability to quantify and prioritize assigned activities, the ability to adapt to changing priorities, and perform duties with minimal supervision. Includes ability to act both independently and as part of a team.

Knowledge: 

• Demonstrated proficient working knowledge of the following: 
  • Medical Terminology
  • Claim audit procedures.
  • Provider contracts
  • Claims processing procedures and guidelines
  • Provider authorizations
  • Provider billing
  • Medical coding
• Proficient working knowledge and experience with reporting capabilities and data analysis.
• Knowledge of the health care industry and Capital corporate structure.
• Knowledge of Capital standards, policies, practices, and procedures of multiple operational areas/systems configurations, including type of service, workflow, etc.
• Familiar with business services, systems and/or processes provided by external business partners.

Experience:

• Minimum three years’ working experience within claims in the healthcare or insurance industry.
• Proficient in conducting cost benefit analysis techniques.
• Strong knowledge of and experience with ICD-10, DRG, CPT/HCPCS coding guidelines.
• Experience with and knowledge of multiple provider reimbursement and pricing methodologies (DRG, SPC, OFS, POC, Global Pricing, Per Diem, etc.)

Education, Certification, and Licenses:

• Bachelor’s Degree preferred in one of the following: Business Administration, Health Planning and Administration, Information Systems, Computer Science, and/or 
• Current Medical Coding certification or obtained within one (1) year of hire date.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must occasionally lift and/or move up to five (5) pounds.
• Sedentary work involving significant periods of sitting, talking, hearing, keying, and performing repetitive motions.
• Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor.
• Working environment includes typical office conditions.

Key Interfaces:

• Ability to communicate effectively with all levels of personnel, both internal and external.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.