Healthcare Services Analyst II

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