Analyst Medical Policy & Analysis II
HealthNow New York Inc. - Buffalo, NY

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Position Summary: 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.

Required Skills Primary Skills/Knowledge: 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

Required Experience Required Experience:

Minimum 3-5 years work experience in medical claims processing required.

Preferred Education:

Bachelors Degree

Preferred Experience:

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.

Working Conditions:

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 - save job - copy to clipboard
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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...