Job description
Job Summary:
The Payment Cycle Analyst II is responsible for providing analytical support and leadership for key Claims-related projects and initiatives.
Essential Functions:
Define clinical and payment policy requirements to support configuration of clinical editing system
Conduct and research potential new reimbursement policy claim edits, including sourcing support, data analysis, consistency with Market regulatory requirements, and network impact.
Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
Conduct both systemic and targeted analysis to identify reimbursement errors and determine root cause
Ensure that all clinical and payment policy analysis and documentation is prepared, reviewed, and approved prior to implementation.
Provide input to UAT and conduct post production validation of implementation results
Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with providers, provider associations, and Health Partner Managers
Document the status of open issues, configuration design, and final resolution
Review and interpret regulatory items, timely delivery of required updates
Provide support of system change policy initiatives, provide updates in payment policy meetings, and present to stakeholders
Monitor configuration and Claim SOPs to ensure accuracy of claim payments
Assist in the development of policies and procedures for claims processing, COB, appeals and adjustment functions
Ensure payment policies and decisions are documented and collaborate with the Health Partner team to ensure information is included in provider education activities
Perform any other job duties as requested
Education and Experience:
Bachelor’s degree or equivalent years of relevant work experience is required
Minimum of three (3) years of health plan experience is required or equivalent experience with provider coding and claim payment policies
Experience working with clinical editing software is preferred
Competencies, Knowledge and Skills:
Advanced proficiency level experience in Microsoft Suite to include Word, Excel, Access and Visio
Strong computer skills and abilities in Facets
Demonstrated understanding of claims operations, configuration, and clinical editing specifically related to managed care
Understanding of CPT, HCPCs and ICD-CM Codes, including strong working knowledge of Codes sets ICD-9/ICD-10, CPT, HCPC, REV, DRG and Rug
Knowledge of HIPAA Transaction Codes
Effective listening and critical thinking skills
Effective problem solving skills with attention to detail
Data analysis and trending skills
Excellent written and verbal communication skills
Ability to work independently and within a team environment
Strong interpersonal skills and high level of professionalism
Ability to develop, prioritize and accomplish goals
Understanding of the healthcare field and knowledge of Medicaid and Medicare
Customer service oriented with strong presentation skills
Strong working knowledge of claims processing edits and logic
Familiar with CMS guidelines / HIPPA and Affordable Care Act
Familiarity with reporting packages and running system reports
Licensure and Certification:
Certified Medical Coder preferred
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Occasional travel (up to 10%) to attend meetings, training, and conferences may be required
Compensation Range:
$62,700.00 - $100,400.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
SalaryOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSourceOriginally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.