Research and Analysis:
Research and respond to low complexity internal and external inquires.
Use a variety of resources including, but not limited to on-line information files and databases, peer guidance, interviews with internal departments including clinical consultants, other Blue Cross/Blue Shield Plans and vendors.
Benefit and policy analysis & implementation:
Learns to assess business impact of new benefits, changes in medical or reimbursement policies/guidelines and tactics assigned in strategic planning.
Learns to conduct cost/benefit analysis of claims processing. Extract and analyze data using SQL, MicroStrategy and/or other tools as available.
Develop documentation, including cost/benefit and business impact analysis and recommendations to implement and/or improve claims processing.
Update and create CES pend resolutions.
Drive implementation of changes through writing of Work Intake Form, participation in multi-department meetings, contribution and review of requirements, validation of test cases, and post-implementation monitoring.
Focus on low complexity project implementations and pend resolution updates.
New Code Implementation:
With the guidance of the Healthcare service analyst II, learns how to load new codes, downloading, processing and importing new codes (CPT, HCPC, ICD-10, etc.).
Prepare and submit files for review and configuration implementation.
Review new codes in assigned categories, work with Medical Management and Configuration to ensure appropriate claims processing/editing based on new code review.
Post-implementation trends and workflow improvements:
Learn how to support audits of implemented policies and completed projects.
Identify and investigate areas involving cost increases, uncontrolled payments and/or inequitable payments.
Identification and resolution of issues and trends as a result of researching and responding to implementation requests, problem reports, and inquiries.
Develop clear, concise documentation complex business scenarios. This documentation will be used to develop policy/project systems and workflow requirements.
Continuing Education:
Attends and successfully completes HMSA and Continuing Education training classes as assigned.
Other duties as assigned.