Payment Policy & Claims Analytics Specialist II

CareSource; United States; Remote; USD 63,000 - 100,000; Full time

Job summary

CareSource is seeking a Payment Cycle Analyst II to provide analytical support and leadership for Claims-related projects and initiatives. You will define clinical and payment policy requirements, research reimbursement edits, and analyze discrepancies affecting claim payments.

The role requires collaboration on UAT, documentation, and stakeholder presentations, with opportunities to influence policy and provider education. General office environment with some travel may apply.

Qualifications

• 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.

Responsibilities

• 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

Skills

Microsoft Office

Facets

Claims operations

CPT/HCPCS/ICD-CM Codes

HIPAA knowledge

Data analysis

Communication skills

Teamwork

Presentation skills

CMS guidelines

Reporting

Education

Bachelor's degree or equivalent

Tools

Facets

Job description

CareSource is seeking a Payment Cycle Analyst II to provide analytical support and leadership for Claims-related projects and initiatives. You will define clinical and payment policy requirements, research reimbursement edits, and analyze discrepancies affecting claim payments.

The role requires collaboration on UAT, documentation, and stakeholder presentations, with opportunities to influence policy and provider education. General office environment with some travel may apply.