The Analyst functions to provide analytical, technical and problem resolution support to Pre/Post Pay Auditing, Claims Editing, COB, and Subrogation processing. Conducts or participates in activities related to planning, controlling and directing projects and analysis. The analyst must use knowledge of existing business practices, systems, procedures, policies, current testing tools/practices and their interrelationships to provide and ensure innovative approaches and solutions to business problems and requirements in the supported systems. The analyst is responsible for obtaining necessary approvals on systems configuration, systems testing and application changes.

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Run simple queries that are already developed.


• Serve as a team member on corporate initiatives and leads departmental initiatives as assigned. Actively participate in projects and/or maintenance and complete assignments timely. Communicate project team status updates verbally and in writing to all team members. Identify projects risks and contingencies. Conduct root cause analysis and identify process improvement opportunities.


• Elicit and document requirements to support maintenance activities (i.e. new Claims Edits).


• Anticipate problems before they occur, document options for solutions, seek necessary approvals, and work with business areas to implement solutions and track progress. Generate and consider options for actions to achieve a long-range goal or vision.


• Research and communicate results in an attempt with the ability to explain complicated data analysis and recommendations to parties with varying degrees of understanding.


• Build strong working relationships with internal and external customers. Summarize verbally and in writing analytical research or explanation of processes. Modify communications to be clear and concise to the intended audience. Communicate delays, risks, and impacts to both management and business areas.


• Independently perform audits and analysis of vendor submitted pre/post-payment claims utilizing standard audit processes to ensure claims identified by vendors for adjustments are accurate through the following techniques:
  
  
  • Research and analysis of applicable provider contract terms and rates
  
  
  • Analysis of member benefits and utilization
  
  
  • Analysis of overarching administrative regulations (Federal, State, BCBSA etc.)
  
  
  • Analysis of appropriate provider coding and billing practices and/or coding guidelines.
  
  
  
  

​JOB REQUIREMENTS

Experience:

Requires the following skills:

• Strong familiarity with ICD-10, DRG, CPT/HCPCS coding


• Experience with and knowledge of multiple provider reimbursement and pricing methodologies (DRG, SPC, OFS, POC, Global Pricing, Per Diem, etc)

Demonstrated proficient working knowledge of at least two of the following:

• Medical terminology & claim audit procedures


• Provider contracts & claims processing procedures and guidelines


• Provider authorizations & provider billing & medical coding

Education and Certifications:

• Prefer a Bachelor’s Degree in one of the following; business administration, health planning and administration, information systems, computer science; and three to five years’ relative experience.

Skills:

• Ability to participate in meetings and effectively communicate impacts to both management and staff.


• Ability to analyze data, determine impact, and develop business solutions for system changes. Ability to act as a liaison and recommend solutions to a variety of departments, as well as other Plans and other external business partners.


• Ability to plan, organize, and participate on projects.


• Ability to effectively communicate in writing and verbally with technical and non-technical audiences. Also includes persuasion and negotiation skills to resolve differences with skill and understanding.


• Ability to quantify and prioritize assigned activities, adapt to changing priorities, and perform duties with minimal supervision. Includes ability to act both independently and as part of a team.

Knowledge:

• Preferred knowledge of the health care industry and/or CBC corporate structure. Includes knowledge of standards, policies, and business practices and procedures for multiple departments/systems. Is familiar with those business services, systems and/or processes provided by external business partners.


• Knowledge of data processing terminology and concepts. Includes a high level technical understanding of technologies such as Microsoft Office Suite, Crystal Reporting and Data Modeling.


• Participates in conducting cost benefit analysis techniques.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.


• The employee must be able to work over 40 hours per week.


• The employee must occasionally lift and/or move up to 5 pounds.!!Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions.


• Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.


• Working environment includes typical office conditions.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.