Position Purpose: Manage and support claims analysis and research. Provide analytical information that identifies process improvement and root cause analysis of issues. Develop and implement solutions to improve overall delivery of claims operations. Ensure claims operation is able to meet or exceed performance measures.
- Manage and mentor Claims Business Analysts.
- Collect, validate and analyze data to deliver business solutions.
- Monitor performance and develop & implement business solutions to address process and/or quality gaps.
- Utilize project management skills to work with cross functional teams on delivery of solutions.
- Promote change through sharing of best practices.
- Leverage automation to achieve desired results.
- Interface with and manage all organizational levels to mobilize commitment.
- Perform claim adjudication project analysis and preparation work flow management.
- Develop and implement required Process Bulletins.
- Identify automation opportunities to decrease spend levels.
- Reduce adjustment volume through root cause analysis and correction.
Education/Experience: Bachelor's degree in a related field or equivalent experience. 5+ years of experience in health plan operations, preferably with Medicare and/or Medicaid or equivalent business experience. Ability to deal with abstract variables and apply principles of logic or scientific thinking to define problems, collect data, establish facts, and draw valid conclusions. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.