Business Analyst

Hybrid Role - onsite in the PA office Tues, Wed, Thurs

The Senior Business Analyst develops and ensures accurate set-up of medical and claim payment policies in accordance with business requirements. The Senior Business Analyst reviews claims data and trends to determine if system enforcement is appropriate or requires adjustment, as well as identifying areas of improvement, system inconsistencies and training opportunities.

DUTIES AND RESPONSIBILITIES:

· Develop policy enforcement requirements based on medical and claim payment policy criteria. Types of enforcement include but are not limited to claim system, prior authorization, desk level procedures, and post-payment review.

· Collaborate with internal business colleagues within the department to gain an understanding of policy criteria, and medical coding rules, to assess systems capabilities.

· Collaborate with other departments and external vendors to ensure the accurate implementation of policies according to business requirements.

· Identify policies that require manual review of policy criteria when systematic enforcement is not an option or not recommended.

· Provide timely documented feedback on issues identified at the system level and execute escalation procedures, including corrective action plans, as applicable.

· Provide quality assurance through development and review of claims data utilization reports to ensure assigned policies are enforced according to business requirements.

· Provide review and resolution of claims incidents resulting from policy set-up issues. Follow-through until all impacted claims are identified and adjusted and provide proper reporting.

· Perform root cause analysis to determine source of policy set-up issues.

· Perform User Acceptance Testing in collaboration with external vendor.

· Provides input to regulatory and other oversight teams regarding adherence to compliance requirements (e.g. CMS, BlueCard processing rules, Product Rules, denial messaging, member/provider liability).

· Interact with all levels of associates and management within the Company and with outside contractors, consultants and other organizations.

· Performs additional related duties as assigned.

QUALIFICATIONS:

· Bachelor's degree in relevant discipline or equivalent work experience.

· Current coding certification (CCS, CPC, RHIA, RHIT) desirable but not required

· Minimum of five years related Claims, Operations or Business Requirement Development experience.

· Must be able to work independently, prioritize workload, meet deadlines, and to assess the criticality of issues.

· Effective time management, shown through the ability to prioritize deliverables and communicate realistic timeframes for resolution.

· Strong problem-solving skills, with a key attention to detail.

· Solid written and verbal communication skills.

· Proven competency with various business tools, such as Microsoft Excel, Word, PowerPoint, SharePoint, and Teams.

· Working knowledge of the organization, business processes, and claims end to end process.