Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit Amidacareny.org for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced individual to join our team as the Medical Informatics Data Analyst. Compensation will be commensurate with experience.

Position Summary:

The Senior Claims Analyst assists management to ensure accurate, timely and proper execution of claims. Assists in quality control and accuracy for claims payments performed by Amida Care's TPA and other specialty vendors. This position will identify opportunities and challenges associated with the end-to-end claims processing life cycle and provide support and resolution to issues This role is also responsible for the proper resolution of provider claim inquiries and correspondence received by the plan to ensure provider satisfaction.

Responsibilities:

• Ensure accurate reimbursement, configuration and implementation of claims payment systems.
• Enter and track provider inquiries/appeals and written correspondence and collaborate internally and with Amida Care's TPA and specialty vendors to provide resolution to ensure provider satisfaction. Identify trends to resolve billing issues and systemic gaps.
• Assist with High dollar reviews by requesting and scanning medical records when applicable.
• Oversight of end-to-end claim system processes to ensure accurate and timely payments to providers.
• Assist Manager and Director to obtain weekly claims inventory dashboard along with analysis on improving claims processing turnaround time and enhancing auto-adjudication rates. Understand and analyze impacts of new program changes such as new benefits, new payment methodologies, new providers, or new populations.
• Monitor and track governmental agencies for updates to annual and quarterly physician fee schedule updates and oversee the accurate and timely implementation into the TPA's claims processing system. Assist with QA effort as appropriate.
• Troubleshoot and identify claim-pricing errors in processing and work with internal departments, TPA and specialty vendors, including Correct Coding vendor, to achieve final resolution and process revision as appropriate.
• Work with network management to resolve provider claim and reimbursement challenges. Ensure providers are billing in accordance with contractual terms.

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

EDUCATION REQUIRED

• High school Diploma or GED.

EXPERIENCES AND/OR SKILLS REQUIRED

• Five years of medical claims analytical/ process ownership required; plus,
• Three (3) years' claims experience in NY Medicaid claims review and analysis, required.
• Knowledge of claims processing rules and coding knowledge with DRG, ICD10 and CPT4, required.
• Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.).
• Knowledge of HIPAA guidelines.
• Ability to manage multiple simultaneous priorities and meet deadlines.
• Strong communications skills (verbal, written, presentation, interpersonal).
• Excellent attention to detail, judgment, analytical, and problem-solving skills.
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes with colleagues and all contacts.
• Demonstrate appropriate behaviors in accordance with the organization's vision, mission and values.