Responsible for organizing and coordinating projects that will improve or enhance the administration of healthcare benefits and care management to AlohaCare’s members. Defines system functionality and develops acceptance criteria. Assists in the design and support of unit or system testing including; data creation, test documentation and summary reporting. Assist and support activities that improve workflows, procedures and processes, including problem identification and resolution, creating and revising documentation and training.
Primary Duties & Responsibilities:
Required Competencies and Qualifications:
- Analyze internal workflows, including but not limited to products and enhancements to add functionality and/or redesign work flows and documentation to improve efficiency. Make recommendations for system or process changes to address current business needs.
- Develop and implement cost/benefit analysis of claims operational functions. Assess business impact of new plans, initiatives, changes in reimbursement policies/guidelines and tactics assigned in strategic planning. Extract and analyze data. Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve operational functions.
- Identify and analyze issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries. Develop clear, concise documentation that describes the trend or issue. This documentation will be used to develop policy/project systems and workflow requirements. Use a variety of resources including but not limited to on-line information files and databases, CMS and other plan guidelines, plan certificates, provider contracts.
- Participates in the development of necessary documents such as scope and design documents. Development of training materials and employee training as needed. Conducts and/or participates in walk through as appropriate. Acts as a liaison with internal customers to facilitate changes or improvements needed to correct problems or improve servicing.
- Defines system functionality for data processing analysts and programmers, including, but not limited to the definition of screens, reports and internal processing, such as edits, calculations, etc.
- Defines acceptance criteria and ensure criteria are met before implementation. Learns to prepare recommendations for consideration by management based on analysis of project results.
- Develops project and testing plans to ensure quality and timely project implementations. Assists in system or unit testing.
- Respond to complex and/or sensitive issues with discretion and judgment using a variety of methods with limited or no direction.
- Minimum 2 years relevant experience with a minimum 2 years of health care industry experience within managed care, hospital, medical office or equivalent.
- Knowledge of healthcare practice standards
- Knowledge of Medicare, Medicaid, and QUEST program
- Knowledge of UB04 and HCFA 1500 claim for billing requirements
- Knowledge of the use of CPT, HCPC, ICD-9, & Revenue codes
- Knowledge of claims system process flow highly desired
- Knowledge of care managements & prior authorization process required.
- Excellent communication and organization skills
- Ability to prioritize, coordinate several tasks simultaneously, and meet deadlines
- Must be detail oriented with internal standards for high quality
- Able to apply practical thinking and decision making
- Able to support team decisions, collaborates with others to develop team solutions, builds consensus, and promotes teamwork through building consensus to develop mutual trust, respect, and commonality of goals.
- Previous experience with documentation of workflows & systems configuration highly desirable
Preferred Competencies and Qualifications:
- Associates degree in Business or related, combined with related work experience.
An Equal Opportunity Employer
- Bachelor’s degree preferred.
- Medical terminology
- Project management experience desirable
- Previous experience with system configuration highly desirable.
- Previous experience with QNXT & QNXT program is highly desirable.
- Knowledge of electronic interfaces, mapping and translation tables highly desirable.
- Previous experience with documentation desirable.
- Excellent communication skills.
- Ability to prioritize, coordinates several tasks simultaneously, and meets deadlines.
- Must be detail oriented.
- Work 8:00am to 5:00 pm Monday-Friday, 40 hours on location.