Healthcare Services Analyst II

Research and Analysis:

Research and respond to low to medium complexity internal and external inquires.

Is proficient at utilizing a variety of resources including but not limited to on-line information files and databases, Medicare/other plan guidelines, plan certificates, provider contracts.

Make recommendations and decisions independently.

Benefit and policy analysis & implementation:

Assess business impact of new benefits, changes in medical or reimbursement policies/guidelines and tactics assigned in strategic planning.

Initiate, develop, coordinate and implement 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 to medium complexity project implementations.

New Code Implementation:

Act as lead in loading of new codes by following existing documented process and timeline for 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:

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.

Software implementation:

Participate in the unit's efforts to implement new projects, software or software modifications.

Participate in the development of user requirements, test scenarios, and test validation activities.

Continuing Education:

Attends and successfully completes HMSA and Continuing Education training classes as assigned.

Other duties as assigned