Operations Analyst

Job Summary

Responsible for sustaining processes and executing process improvement and quality monitoring within Claims Operations and the business processes impacted by Operations data and systems.

Essential Functions

• Be responsible for State and CMS claims benefit application, pricing and oversight of benefit configuration.

• Monitor compliance with State, CMS, OIC requirements (claims benefit configuration, claims timeliness, claim denials, encounter data submissions).

• Gather business requirements for claims benefit configuration to support system enhancements and implementation of new products.

• Facilitate the development and execution of user acceptance scenarios and scripts for testing of system changes, implementations and enhancements. Peer review and support system enhancements and configuration of vendor systems.

• Subject matter experts for all State, CMS, OIC audits; TEAMonitor, HEDIS, NCQA, CMS Financial, Data Validation, ODAG, Timeliness

• Oversight of State, CMS, OIC Encounter Data Reporting. 

• Provide support for electronic data interchange (EDI) data files. Create business requirements, perform user acceptance testing and implementation for updates of EDI transactions.

Qualifications

Education

• Bachelor’s degree (in health care or related field) or an equivalent combination of education and highly relevant experience required.

Experience

• Minimum of 3 years’ managed care/health plan operations experience required, with proven broad knowledge and execution of quality improvement methods and tools.
• Minimum 2 years business/operations analysis experience in a related field required.
• Background in claims adjudication, benefits configuration, claims coding, electronic data interface, encounter data reporting preferred.
• Medicaid and Medicare experience preferred.

Employment Eligibility

• Complete and successfully pass a criminal background check
• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency

Knowledge, Skills, and Abilities

• Understanding of the healthcare industry, specifically in the Operations area.
• Project management skills and team facilitation skills.
• Strong communication skills, both verbal and written.
• Strong technical and process documentation skills.
• Strong analytical skills.
• Demonstrated ability to work well with different people at all levels within the organization.
• Ability to multi-task, prioritize, and work under pressure.

CHPW OFFERS ROBUST TOTAL REWARDS

The position is FLSA Exempt (salary) and is not eligible for overtime. The position is also eligible for as an annual incentive based on company, department, and individual performance goals. Full and Part - time employees have the option to enroll in medical, dental, vision and voluntary life insurance benefits, and 401(k) retirement benefits effective the 1^st of the month following or coinciding with their start date. CHPW provides a 6% 401(k) employer match, Basic Life, Accidental Death and Dismemberment insurance, short and long-term disability, financial coaching, and wellness programs at no cost. 

CHPW employees start earning 17 days of Paid Time Off (PTO) and receive 40 hours of community service for volunteer time, and two floating holidays immediately. The company offers 10 standard holidays, paid jury duty and compassion time.

CHPW offers a monthly stipend to offset work-from-home expenses for roles that are 100% remote.

SENSORY/PHYSICAL/MENTAL REQUIREMENTS

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending and twisting
• Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching

Mental:

• Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

WORK ENVIRONMENT

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

PROTECTED HEALTH INFORMATION (PHI) ACCESS

All information (written, verbal, electronic, etc.) that an employee encounters while working at CHPW is considered confidential.  CHPW employees may encounter protected health information in the regular course of their work at and for CHPW.  This position may be exposed to and required to deal with highly confidential and sensitive material and must adhere to CHPW policies, guidelines, and all applicable laws and regulations at all times. 

*Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

This job description is intended to describe the general content and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.