Healthcare Services Analyst II

Responsibilities

• Research and respond to low to medium complexity internal and external inquires.
• Utilize a variety of resources including on-line information files and databases, Medicare/other plan guidelines, plan certificates, provider contracts to 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 as available.
• Create and update documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
• Write Work Intake Forms, participate in multi-department meetings, contribute and review requirements, validate test cases, and monitor post-implementation processes.
• 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.
• Develop clear, concise documentation complex business scenarios.
• Attend and complete HMSA and Continuing Education training classes as assigned.

Qualifications

• 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.