Role Overview:
The Enterprise Operations Solutions Analyst is a subject matter expert and analyst on all research and analysis of provider claim issues and escalated complaints that are referred by state agencies, plans, providers, or other departments.
Work Arrangement:
- Remote - Associate can work remotely anywhere in the United States.
- Some travel may be needed for business meetings.
Responsibilities:
- Responsible for supporting business processes and practices for all Lines of Business
- May need to support critical efforts outside of normal business hours, dependent on department need
- Function as a key subject matter expert for all research and analysis of provider claim payment issues
- Identify and present root causes and recommended corrections for complex operational claim payment problems that may result in policy changes, provider education, and system configuration changes.
- Develop and maintain tracking mechanisms to identify and address provider claim issues and escalated complaints through remediation.
- Analyze trends related to claim experience to identify potential issues before they arise proactively.
- Inform and influence the claims process for new initiatives or services.
- To effectively provide technical expertise, the employee must maintain a current working knowledge of processing rules, contractual guidelines, plan policy, and operational procedures.
- Develop business models and documentation to support business decisions, workflows, and processes.
- Focus on technology and business issues and communicate appropriately with technology and business experts.
- Utilize various technology applications to track, trend, and store information related to claims processing, provider maintenance, and member eligibility.
- Build business cases that will enable business and technology change based on requirements.
- Act as a liaison and participate in defining, conveying, and documenting business requirements to solve complex claims issues, business issues, or problems.
- Provide documentation for requirements, meetings, changes, interfaces, reports, and overall workflow.
Education & Experience:
- Bachelor’s Degree or equivalent experience.
- 2 to 3 years of healthcare experience with claims, encounters, and/or research and analysis.
- Billing and coding experience is a plus
- Extensive claims payment knowledge with critical thinking skills.
- Strong with Microsoft Office Suite (Excel, Access, Word), and SQL
Skills & Abilities:
