Operations Operational Analyst IV

Responsible for operationalizing business and/or regulatory requirements, including payment integrity process improvement and work related for developing prospective claims editing while utilizing clinical coding and reimbursement policies.

Must be subject matter expert in Payment Integrity vendor relationships.

This role will drive planning and execution of initiatives related to Payment Integrity Growth and Optimization. They will be highly engaged and aligned with the Payment Integrity vendors and all related internal teams and external vendor partners.

The incumbent has detailed expertise around the lifecycle of a claim and how Payment Integrity affects adjudication. In addition, they will be able to create new prospective edits and analyze existing edits to cultivate a robust Payment Integrity offering. They will be responsible for compiling, collecting, analyzing, reporting and presenting product data to various stakeholders.

Skills and Abilities

• Knowledge and experience working with Payment Integrity vendors and FWAE initiatives preferred
• Knowledge and experience of claim operations, health care reimbursement, public health care programs (Medicare & Medicaid) and reimbursement methodologies. Health Care Payer experience preferred.
• Outstanding oral and written communication skills, with demonstrated ability to communicate effectively with all levels within the organization and external partners
• Strong critical thinking skills, including the ability to understand cause and effect relationships
• Demonstrated ability to lead, influence change, initiate and shape work with colleagues inside and outside the organization to achieve goals
• Intermediate to Advanced skills in Microsoft product suite

• Knowledge of Medical Coding, Compliance, Payment Integrity and Analytics. Certified Coder Preferred.
• Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e. Center for Medicare & Medicaid Services (CMS) & Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.)

Minimum Qualifications

Bachelor's degree or equivalent experience in related field, plus 7 years of related work experience beyond degree. Years of experience in lieu of education is acceptable.

The full salary range for this position is $61,500-$105,400. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.