Healthcare Services Analyst II

HMSA; Honolulu (HI); On-site; USD 70,000 - 95,000; Full time

Job summary

HMSA in Hawaii is seeking a Research and Policy Analyst to support benefit and policy analysis, coding implementation, and post-implementation reviews. The role involves researching inquiries, analyzing data with SQL and MicroStrategy, and making independent recommendations to improve claims processing.

You will lead loading of new codes (CPT, HCPCS, ICD-10), support audits and documentation, and collaborate across departments to implement changes.

Qualifications

• Proficient at researching and responding to inquiries of low to medium complexity.
• Ability to extract and analyze data using SQL, MicroStrategy and other tools.

Responsibilities

• Research and respond to low to medium complexity internal and external inquiries.
• 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.
• Lead in loading of new codes by following existing documented processes (CPT, HCPC, ICD-10, etc.).
• Support audits and post-implementation reviews of policies and projects; identify cost increases and inequities.
• Participate in software implementation efforts and validation activities.
• Attend HMSA Continuing Education training classes as assigned.
• Perform other duties as assigned.

Skills

Data analysis

Independent decision making

Research skills

Tools

SQL

MicroStrategy

Job description

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. Continuing Education

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

7. Other duties as assigned