Position Summary: Under the direction of Utilization Management, the Analyst Medical Policy & Analysis II is responsible for proactively performing claim audits in order to test, analyze, and ensure consistency and accuracy of (a) core system edits; (b) business processes and workflows; and (c) classification of codes. In addition, this position plays a primary role in the management of our clinical editing system. The incumbent may also research or investigate complex medical payment issues which may result in referrals to other areas, such as determining whether fraud or abuse occurred or for education of our provider network.
Primary Job Duties:
Assists in achieving Medical Expense and Affordability targets by planning, conducting, and supervising post pay claim audit and analysis. Evaluates operational systems, processes, and workflows to reduce/eliminate errors, track progress and results, and recommend changes.
Assists in the management of the clinical editing system and acts as a liaison to our clinical editing software vendor. Maintains advanced knowledge of all clinical edits that are applied to our system. Manages the annual merge update to ensure that all new edits are applied correctly and all customizations are reapplied as necessary. Develops the requirements for clinical editing system changes or business process changes. Responsible for monitoring the configuration and testing of identified change requests.
Assists in analysis of new regulations, laws or group specific contract requirements to determine possible impact on existing policies. Recognizes and resolves issues/conflicts between the intent of the member contracts and the provider contracts relative to reimbursement policies.
Leads and/or participates on provider reimbursement and code editing teams to support Medical Services requirements, policies, and initiate/implement resolutions of identified issues. (10%)
Performs other related duties as assigned.
Exceptional understanding of Facets claims processing and payment
Thorough understanding of ICD-9 procedure and diagnosis and CPT/HCPC coding as well as inpatient, outpatient, and professional claims pricing
Excellent analytical skills which include the ability to audit large volumes of data or claims, analyze trends, identify issues, and produce both high-level concise as well as transparent detail-level reporting.
Knowledge of business rules policies as well as products for commercial, government, and ASO contracts
Demonstrated personal accountability
Excellent time and project management skills
Excellent organizational skills and attention to detail
Persuasive communication style with excellent verbal and written communication skills
Ability to work effectively with minor supervision
Must be able to work in a fast-paced environment with daily work processing deadlines
High degree of business maturity and demonstrated confidentiality
High energy level and ability to project enthusiasm
Polished, professional image and reputation
Advanced proficiency in Facets, Pegasystem, MS Word, MS Excel, Lotus Notes, Internet
Intermediate proficiency in Cognos, MS Access, MS PowerPoint, Visio
Knowledge of medical terminology
Knowledge of core healthcare systems and functionality
Minimum 3-5 years work experience in medical claims processing required.
5-8 years experience in a medical management environment required. Combination of equivalent education and/or work experience may be substituted. Experienced in the management of clinical editing systems and in audit process preferred.
Must be able to work in an office environment
Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize (a) a computer with all its components for prolonged periods of time and for the majority of required tasks; and (b) various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc.
Required Licenses/Certifications: none
HealthNow New York Inc. - 21 months ago
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HealthNow New York Inc. is one of New York’s leading health care companies that provide access to quality health care and innovative...