Healthcare Services Analyst II

Pay Range: $47,500 - $88,000

Note: Individuals typically begin between the minimum to middle of the pay range

Responsible for the research, analysis, development, and implementation of new/revised reimbursement policies, benefits, and contracts. This analyst performs all activities related to the appropriate administration of these activities, which are based on a strong working knowledge of HMSA's business as well as medical, benefit, contracting, and reimbursement policies/edits. Is able to analyze and present large amounts of data clearly.

Acts as lead on the timely loading of new codes.

Works with multiple departments to implement complex guidelines, laws or policies from various sources including CMS, CDC, and other carriers.

• Bachelor's degree or equivalent combination of education and work experience.

• Two years of related work experience.

• Effective verbal, written communication skills

• Excellent organizational and analytical skills

• Must possess working knowledge of medical terminology, anatomy, and health plan benefits.

• Good working knowledge of Microsoft Office programs

• Research and Analysis:
  
  • Research and respond to low to medium complexity internal and external inquires.
  • Is proficient at utilizing 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.

• 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 low to medium complexity project implementations.

• New Code Implementation:
  
  • Act as lead in loading of new codes by following existing documented process and timeline for downloading, processing and importing new codes (CPT, HCPC, ICD-10, etc.).
  • Prepare and submit files for review and configuration implementation.
  • Review new codes in assigned categories, work with Medical Management and Configuration to ensure appropriate claims processing/editing based on new code review.

• Post-implementation trends and workflow improvements:
  
  • Support 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.

• 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.

• Continuing Education:
  
  • Attends and successfully completes HMSA and Continuing Education training classes as assigned.

• Other duties as assigned