Job Summary:

The Payment Cycle Analyst II is responsible for providing analytical support and leadership for key Claims-related projects and initiatives.

Essential Functions:

• Define clinical and payment policy requirements to support configuration of clinical editing system
• Conduct and research potential new reimbursement policy claim edits, including sourcing support, data analysis, consistency with Market regulatory requirements, and network impact.
• Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
• Conduct both systemic and targeted analysis to identify reimbursement errors and determine root cause
• Ensure that all clinical and payment policy analysis and documentation is prepared, reviewed, and approved prior to implementation.
• Provide input to UAT and conduct post production validation of implementation results
• Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with providers, provider associations, and Health Partner Managers
• Document the status of open issues, configuration design, and final resolution
• Review and interpret regulatory items, timely delivery of required updates
• Provide support of system change policy initiatives, provide updates in payment policy meetings, and present to stakeholders
• Monitor configuration and Claim SOPs to ensure accuracy of claim payments
• Assist in the development of policies and procedures for claims processing, COB, appeals and adjustment functions
• Ensure payment policies and decisions are documented and collaborate with the Health Partner team to ensure information is included in provider education activities
• Perform any other job duties as requested

Education and Experience:

• Bachelor6s degree or equivalent years of relevant work experience is required
• Minimum of three (3) years of health plan experience is required or equivalent experience with provider coding and claim payment policies
• Experience working with clinical editing software is preferred

Competencies, Knowledge and Skills:

• Advanced proficiency level experience in Microsoft Suite to include Word, Excel, Access and Visio
• Strong computer skills and abilities in Facets
• Demonstrated understanding of claims operations, configuration, and clinical editing specifically related to managed care
• Understanding of CPT, HCPCs and ICD-CM Codes, including strong working knowledge of Codes sets ICD-9/ICD-10, CPT, HCPC, REV, DRG and Rug
• Knowledge of HIPAA Transaction Codes
• Effective listening and critical thinking skills
• Effective problem solving skills with attention to detail
• Data analysis and trending skills
• Excellent written and verbal communication skills
• Ability to work independently and within a team environment
• Strong interpersonal skills and high level of professionalism
• Ability to develop, prioritize and accomplish goals
• Understanding of the healthcare field and knowledge of Medicaid and Medicare
• Customer service oriented with strong presentation skills
• Strong working knowledge of claims processing edits and logic
• Familiar with CMS guidelines / HIPPA and Affordable Care Act
• Familiarity with reporting packages and running system reports

Licensure and Certification:

• Certified Medical Coder preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Occasional travel (up to 10%) to attend meetings, training, and conferences may be required

Compensation Range:

CareSource takes into consideration a combination of a candidate6s education, training, and experience as well as the position6s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee6s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business