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

Healthcare Services Analyst II

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