The position will be accountable to partner with other areas including Service, Performance Guarantee Audit, IT service area, and the Investigations area to generate ideas, analyze/prioritize the potential and the feasibility, determine the savings and cost, and ultimately implement execute the action plans, in order to maximize the cost reduction outcomes.To support the manager and the team in achieving the cost reduction goals, the position will be responsible for:
- Collecting comprehensive claim data and the related data that impacts the payment process integrity.
- Trending analysis on medical services, provider billing status, and member utilizations.
- Coordinate and analyze data/information received and collected from various internal and external sources.
- Performing payment data review throughout the claim process including but not limited to member benefit, provider contract, system code loading, and IT configuration.
- Identify potential control deficiency and analyze the potential payment impact.
- Provide strong assistance to the manager and peers in creating tools; deliver quality data and executing action plan with high preciseness.
- Maintain effective and efficient work relationship with all related areas to maximize integrity and minimize payment irregularity.
- Supports root cause analysis, supports investigations for claim recovery opportunities, analyzes findings to identify trends, resolution and implementation for recovery and avoidance of future overpayments.
- Able to handle all end to end projects including review claim from EDI inception through payment generation along with benefits processing, provider contracting processing, and NASCO module/table interaction.
- Process and Monitor claim recaps to ensure the materialization of estimated cost savings.
- Bachelor's degree is required.
- Requires 5-7 years business experience.
- Requires 5 years or more healthcare and managed care experience. Health plan products and vendor experience preferred.
Requires 3 of the following requirements:
- 2-3 years experience managing multiple complex projects simultaneously.
- 2 plus years prior internal or external audit experience.
- 3 to 5 years experience in analyzing data, drawing conclusions, applying an analytical/quantitative approach to problem solve and resolve issues.
- 3-5 years experience in claim processing (including pricing and code editing), NASCO system and various benefit and ancillary systems.
- Past experience in business process improvement and system implementations in a fast-paced, high pressure environment is preferred.