Claims Bus Tech Analyst II

Industry: Misc. Healthcare


5 - 7 years

Posted 342 days ago

Job Summary:

This technical analyst position is required in order to create a critically needed Service Division Claims Business Technical team to support the successful implementation of automation and efficiency projects/programs to ensure the achievement of claims timeliness and quality goals.

More specifically the Claims Business Technical Analyst will be responsible for coordination throughout the Service Division of all Claims Operations' technical requirements including global inventoryreporting and agedclaims analysis; claims stop governance, monitoring and maintenance; NASCO issue coordination and system request prioritization, submission and installation; Qblue issue coordination; files and table management; BRD review and subject matter expertise; Open Connect and BPM opportunity assessment and execution; EDI gateway claim edit project assessment and completion; general business level technical support for CSRs, PLogs, configuration, file updates and other projects.


  • Provides business technical support to operations across the Service Division to ensure successful implementation of automation and efficiency projects/programs to ensure the achievement of claims timeliness and quality goals.
  • Works with Service departments to coordinate prioritization of projects and works with IT and Claims System vendors (NASCO, Qblue) for implementation.
  • Collaborates with the business groups to develop, document and standardize reporting procedures and workflows to support operational improvement.
  • Manages Claims Stop governance and maintenance to minimize claims stops and assure discipline, documentation and audit trail.
  • Leverages existing technology by identifying opportunities to automate manual processes and interventions; identify opportunities to incorporate and standardize new technology into processes and flows.
  • Creates opportunities by working with IT on new solutions and business on EDI gateway claim editing possibilities.
  • Works with IT and corporate departments to help monitor service level agreements on Plog timeliness; recommends alternate approaches for handling for effectively.
  • Work across Service departments to achieve business goals; leverage key internal and external relationships to access the information, products and resources (technology, training, staff, etc.) necessary to successfully support Claims and related Service goals.
  • Reviews BRDs and offers commentary as required.
  • Provides Subject Matter expertise to Service teams as needed on business technical issues.
  • Performs other duties as assigned.
  • Provides post-implementation check out of system enhancements and thorough overview of enhancements to business owners.
  • Configures updates and programs code to over 50 plan maintainable tables and claims routing criteria
  • Troubleshoots system issues, determines root cause and resolution, and responds to Plogs accordingly.
  • Reviews reports with BPM and Navigator to evaluate output and controls; monitors unassigned claim work baskets and coordinates with Team Leaders.
  • Ensures the Application is stable and operational for daily work and functionality; updates Claims Team as required.



  • Requires broad understanding of claims systems and related ancillary systems used in the Service Division.
  • Requires business and/or technical expertise from previous claims projects and work flow changes and impacts.
  • Requires knowledge of the deep understanding of the QBLUE and/or NASCO system.
  • Requires knowledge of project management life cycles and related tools and practices.
  • Must have a solid understanding of claim processing including pricing and code editing.
  • Must have strong organizational and analytical skills and demonstrated ability to effectively manage multiple projects at one time.
  • Must have strong inter-personal skills with a demonstrated ability to lead cross-divisional work teams.
  • Must demonstrate an understanding of the interdependences between the business, clinical and financial side of the health care business.
  • Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project) and Lotus Notes; Should be knowledgeable in the use of intranet and internet applications.
  • Must have a working knowledge of the impacts of mandates and legislation on overall claims processing and contracting.

Skills and Abilities:

  • Requires technical proficiency in Horizon claims operating models.
  • Requires excellent coordination management and organizational skills.
  • Requires strong analytical and problem solving skills.
  • Require excellent conflict management and relationship management skills.
  • Requires excellent facilitation, coaching and platform skills.
  • Requires strong project management skills based on Horizon project management practices.
  • Requires ability to work on a matrix-managed project team.


  • Bachelor’s degree is required.
  • In lieu of Bachelors degree, an additional 3 years of experience in Operations or IT is required
  • Requires broad-based Operations or IT experience with a minimum of 5 years in managedhealthcare or related industry.
  • Successful track record in managing operations with process improvement background desired Past experience on system implementations in a fast-paced, high pressure environment is preferred In depth Claims systems knowledge is required.
  • Project management experience is a plus.
  • Experience with specialty health plan products/groups helpful.
  • Prior background in managing change and developing new operations is preferred.

Job ID:  GMR082017-10208