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Payment Cycle Analyst

at CareSource

Posted: 6/14/2019
Job Reference #: *D7F66502FF2C021D
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Job Description

Requisition Number
19-0245

Post Date
5/28/2019

Title
Payment Cycle Analyst

City
Atlanta

State
GA

Description

Role and Responsibility:

  • Provide analytical support and leadership for key Claims-related projects and initiatives
  • 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 related instructions, as requested


Requirements

Education / 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

Required Competencies / Knowledge / 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 / Certification:

  • Certified Medical Coder preferred

Working Conditions:

  • General office environment; may require sitting/standing for long periods of time