- 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 medium to high complexity project implementations.
- Lead on enterprise or multi-year projects.
- Research and Analysis:
- Research and respond to medium to high complexity internal and external inquires.
- Utilize 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.
- 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.
- Post-implementation trends and workflow improvements:
- Lead 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.
- New Code Implementation:
- Review new codes in assigned categories, work with Medical Management and Configuration to ensure appropriate claims processing/editing based on new code review.
- Project Coordination:
- Assists Coordinator or leads project coordination, with minimal/appropriate oversight, the initiation, planning, and implementation phases of unit, department, cross department, or enterprise wide projects and activities as well as post-implementation activities through the following:
- Leads/assists in the project planning process with other business owners, stakeholders, and representatives from other units/departments
- Creates workflows and progress schedule to ensure alignment with project/activity goals.
- Understands the current "AS-IS" process, identifies or defines the business need and scope
- Gathers the business requirements, impact and final recommendations for implementation
- Tracks progress and provides status to other stakeholders
- Post-implementation coordination of audits, monitoring and post-payment review as needed based on size impact.
- Management Assistance:
- Contributes to team effectiveness by analyzing operating functions in order to create and revise systems and procedures used to implement new and improve existing operational efficiencies.
- Represents the unit and department in various corporate activities.
- Training (Enterprise & Unit):
- Assists in creating/reviewing training material, conducts formal training sessions with staff, and communicates results of analysis to individual groups of internal and external customers. May include enterprise-wide training or presentations. Methods of communication can include but are not limited to scheduled meetings, conference calls, memos, training documents, claims filing instructions, pend resolution instructions.
- Creates and maintains training material and conducts formal training sessions with BIM staff through one-on-one and group sessions to communicate new or revised business requirements that affect workflows.
- Continuing Education:
- Attends and successfully completes HMSA and Continuing Education training classes as assigned.
- Other duties as assigned
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HMSA
Dec 19, 2024 