Business Analyst – Operations Performance

Business Analyst – Operations Performance

Requirements

• Demonstrated ability to analyze problems, probe facts, identify and question assumptions and find creative and effective solutions to meet business goals without compromising customer satisfaction.
• Requires three (3) years of progressively responsible heath plan experience.
• Requires highly effective verbal and written communication skills and good organizational skills.
• Requires knowledge of medical terminology, medical codes, and related reference materials.
• Excellent problem solving, organizational, and analytical abilities.
• Experience with Microsoft Excel.
• Associates degree in a related field.
• Additional years of qualifying work experience may be considered in lieu of formal education.

Responsibilities

• Collect, organize, and analyze information within vendor systems and reports.
• Collaborate with vendor partners to ensure seamless alignment of business processes with the vendor system.
• Evaluate the effectiveness of integration efforts and support continuous improvement initiatives.
• Develop and deliver reports and presentations to stakeholders, including senior management to drive informed decision-making and ensure transparency in efforts.
• Foster a work environment of continuous improvement Collaborate with internal stakeholders to include senior management to ensure comprehensive and efficient resolution of issues and development of process improvement.
• Comprehensively review and evaluate second level appeals. Determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
• Provide written acknowledgment of member for second level appeals.
• Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
• Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, policies and procedures, best practices, and performance issues.
• Prepare written responses to OPM for second level appeals that appropriately address each complainant’s issues and are structurally accurate.
• Plans, schedules, and facilitates meetings.
• Develops, tracks, monitors, and communicates project progress against the project plan.
• Coordinates the input, process, support, and communication with all functional areas that impact or are impacted by project scope, business value, risk, and resource requirements.
• Ensures integration of the project activities to meet schedule, deliverables, and manages process changes to achieve customer requirements.
• NSA/IDR review and reporting
• Audits claims, reports or electronic files for accuracy, benefit payment, and compliance with policies and procedures.
• Prepares and presents quality audit reports for management to identify trends, issues, and performance.
• Manage the yearly ID card file.
• Complete yearly 1095B and 1099 process.
• Complete audit reviews of QA work/output from UMR to include, but not limited to: Calls, claims, eligibility & enrollment, appeals, payment integrity and Provider data management.
• Calibrate with QA team at UMR to ensure results are in alignment; escalate when outcomes cannot be aligned.
• Complete audit reviews
• Actively engage and demonstrate characteristics of a collaborative team member.
• Other duties as assigned.

Preferred Qualifications

• Additional years of qualifying work experience may be considered in lieu of formal education.