Payment Cycle Analyst III
Job Summary:
Payment Cycle Analyst III is responsible for conducting both systemic and targeted analysis to identify reimbursement errors and to determine root cause. As well as collaborating with Configuration, Configuration UAT, Enterprise UAT, IT Claims, and Payment Cycle Team members to ensure test scripts are comprehensive.
Essential Functions:Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members
Research and provide recommendations to the Reimbursement Committee for reimbursement of services
Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders
Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties
Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events
Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements
Identify test result outputs and Claim SOPs that need to be modified or created to support new or changed business requirements
Build library of re-usable tests plans & scripts to support the Market
Document the status of test results and gaps in testing for future improvements
Validate Impact Reports to ensure the criteria is consistent with story and universe of claims impacted by the changes
Approve UAT test scripts and test results prior to promoting changes to production and monitor post production results
Validate MCA Tests for expected results and communicate information to Reimbursement Analysts and HP Managers for provider notification
Conduct both systemic and targeted analysis to identify issues with testing and identify process changes for improvement
Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups
Perform any other job related duties as requested.
Education and Experience:Bachelor's degree required
Equivalent years of relevant work experience may be accepted in lieu of required education
Five (5) years of health plan experience is or equivalent experience with health plan operations and configuration required
Experience with user testing required
Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) preferred
Competencies, Knowledge and Skills:Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio
Strong computer skills and abilities in Facets or equivalent claim payment system is preferred
Strong analytical skills with the ability to effectively communicate findings with the Leadership Team
Demonstrated understanding of claims operations, configuration, and testing related to managed care
Understanding of regression, unit, and user acceptance testing is required
Effective listening and critical thinking skills
Effective problem-solving skills with attention to detail
Creative thinking to develop positive and negative test scenarios
Excellent written and verbal communication skills
Ability to work independently and within a team environment
Strong interpersonal skills and high level of professionalism
Ability to develop, prioritize and accomplish goals
Understanding of the healthcare field and knowledge of Medicaid, Medicare, and Marketplace
Strong working knowledge of claims processing edits and logic
Familiar with CMS guidelines / HIPPA and Affordable Care Act
Licensure and Certification: None required
Working Conditions:General office environment; may be required to sit or stand for extended periods of time
Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required
Compensation Range:
$72,200.00 - $115,500.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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