Summary:
This position is responsible for all related aspects of the claims systems processes. For this essential, fast-paced Claims Systems role, you will manage complex Claims Systems projects and implementations within the claims adjudication engine. Will ensure data integrity, data security and process optimization for EviCore Claims processing. In addition, you will perform documentation and development of application functionality and data configuration.
Responsibilities:
• Works independently and complete tasks with minimal supervision
• Work from Azure Dev ops utilizing project methodologies to maintain and upkeep tickets for Claim System projects and requests
• The Lead analyst will mentor the Sr. Analyst on complex enhancement and configuration designs
• Provide support as a Claim Systems subject matter expert to internal departments such as but not limited to Claims Configuration, Client Engagement, Program leads, Claims IT Development team
• Lead external client calls to support clients in all aspects of the Claim System application
• Define business, technical, and claim data exchange requirements.
• Instruct on data file mapping (such as provider, member, authorizations, claims, etc.)
• Create test/use cases, perform SI testing, and provide support for associated UA testing in order to successfully complete EviCore claims systems client implementations, internal integration/migration efforts.
• Create simple to complex SQL queries to review Claim system configuration and claims data
• Make updates to configuration via Access Database
• Run Postproduction review on claims to validate changes deployed to production are processing as expected
• Investigate claim processing to determine Claim Configuration root cause analysis
• The associate will be responsible for collaboration and oral/written communication with internal and external client business operations, IT departments and QA departments to support these requirements.
• Additional responsibilities may include assisting the reporting development team, RFP data processing requests, training, maintenance transition and process/product workflow/documentation.
• This associate will perform duties under self-direction and is expected to make decisions as necessary.
Requirements:
• Bachelor Degree in a computer related field preferred or equivalent work experience
• 5+ years of claims and health care experience required
• 5+ years of experience in medical Claims Systems Configuration preferred
• Experience running complex queries utilizing Microsoft SQL
• Proficient in Microsoft Access Database (including queries and data manipulation) is required
• Proficient in Microsoft Excel (including pivot tables, charts and formulas) is required
• Strong technical competence, proven critical thinking, and impeccable communication skills are required
• Accomplished in claims lifecycle knowledge and claims adjudication framework
• Industry standard claims data types and editing rules (ICD, CPT/HCPC, Rev Codes, NCCI).
• Familiarity with database management systems (DB2, SQL Server)
• External client facing experience preferred
• Creating test plans/use cases, and SDLC models.
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
