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- Research and Analysis:
- Research and respond to low complexity internal and external inquires.
- Use a variety of resources including, but not limited to on-line information files and databases, peer guidance, interviews with internal departments including clinical consultants, other Blue Cross/Blue Shield Plans and vendors.
- Benefit and policy analysis & implementation:
- Learns to assess business impact of new benefits, changes in medical or reimbursement policies/guidelines and tactics assigned in strategic planning.
- Learns to conduct cost/benefit analysis of claims processing. Extract and analyze data using SQL, MicroStrategy and/or other tools as available.
- Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
- Update and create CES pend resolutions.
- Drive implementation of changes through writing of Work Intake Form, participation in multi-department meetings, contribution and review of requirements, validation of test cases, and post-implementation monitoring.
- Focus on low complexity project implementations and pend resolution updates.
- New Code Implementation:
- With the guidance of the Healthcare service analyst II, learns how to load new codes, downloading, processing and importing new codes (CPT, HCPC, ICD-10, etc.).
- Prepare and submit files for review and configuration implementation.
- Review new codes in assigned categories, work with Medical Management and Configuration to ensure appropriate claims processing/editing based on new code review.
- Post-implementation trends and workflow improvements:
- Learn how to support audits of implemented policies and completed projects.
- Identify and investigate areas involving cost increases, uncontrolled payments and/or inequitable payments.
- Identification and resolution of issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries.
- Develop clear, concise documentation complex business scenarios. This documentation will be used to develop policy/project systems and workflow requirements.
- Continuing Education:
- Attends and successfully completes HMSA and Continuing Education training classes as assigned.
- Other duties as assigned.
Qualifications
- Bachelor's degree or equivalent combination of education and work experience.
- One year related work experience.
- Effective verbal, written communication skills
- Excellent organizational and analytical skills
- Good working knowledge of Microsoft Office applications.
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