Payment Cycle Analyst II

Job Summary:

The Payment Cycle Analyst II is responsible for providing analytical support and leadership for key Claims-related projects and initiatives.

Essential Functions:

Define clinical and payment policy requirements to support configuration of clinical editing system

Conduct and research potential new reimbursement policy claim edits, including sourcing support, data analysis, consistency with Market regulatory requirements, and network impact.

Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates

Conduct both systemic and targeted analysis to identify reimbursement errors and determine root cause

Ensure that all clinical and payment policy analysis and documentation is prepared, reviewed, and approved prior to implementation.

Provide input to UAT and conduct post production validation of implementation results

Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with providers, provider associations, and Health Partner Managers

• Document the status of open issues, configuration design, and final resolution
• Review and interpret regulatory items, timely delivery of required updates
• Provide support of system change policy initiatives, provide updates in payment policy meetings, and present to stakeholders
• Monitor configuration and Claim SOPs to ensure accuracy of claim payments
• Assist in the development of policies and procedures for claims processing, COB, appeals and adjustment functions
• Ensure payment policies and decisions are documented and collaborate with the Health Partner team to ensure information is included in provider education activities
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree or equivalent years of relevant work experience is required
• Minimum of three (3) years of health plan experience is required or equivalent experience with provider coding and claim payment policies
• Experience working with clinical editing software is preferred

Competencies, Knowledge and Skills:

• Advanced proficiency level experience in Microsoft Suite to include Word, Excel, Access and Visio
• Strong computer skills and abilities in Facets
• Demonstrated understanding of claims operations, configuration, and clinical editing specifically related to managed care
• Understanding of CPT, HCPCs and ICD-CM Codes, including strong working knowledge of Codes sets ICD-9/ICD-10, CPT, HCPC, REV, DRG and Rug
• Knowledge of HIPAA Transaction Codes
• Effective listening and critical thinking skills
• Effective problem solving skills with attention to detail
• Data analysis and trending skills
• 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 and Medicare
• Customer service oriented with strong presentation skills
• Strong working knowledge of claims processing edits and logic
• Familiar with CMS guidelines / HIPPA and Affordable Care Act
• Familiarity with reporting packages and running system reports

Licensure and Certification:

Certified Medical Coder preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Occasional travel (up to 10%) to attend meetings, training, and conferences may be required