Conduct both systemic and targeted analysis to identify reimbursement errors and to determine root cause
Collaborate with Configuration, Configuration UAT, Enterprise UAT, IT Claims, and Payment Cycle Team members to ensure test scripts are comprehensive
Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members
Research and provide recommendations to the Reimbursement Committee for reimbursement of services
Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders
Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties
Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events
Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements

Bachelor's degree required
Five (5) years of health plan experience or equivalent experience with health plan operations and configuration required
Experience with user testing required
Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) preferred
Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio
Strong computer skills and abilities in Facets or equivalent claim payment system is preferred
Strong analytical skills with the ability to effectively communicate findings with the Leadership Team
Demonstrated understanding of claims operations, configuration, and testing related to managed care
Understanding of regression, unit, and user acceptance testing is required

Payment Cycle Analyst III

Key skills