Job Description Summary

The Claims Business Analyst reports to the Director of Claims and is responsible for a range of activities that ensure the operational effectiveness and excellence of the Claims department. The incumbent is responsible for driving process improvement activities within the Claims department, conducting discovery activities with subject matter experts, documenting business processes and identifying opportunities to improve from a process or technical standpoint. The Claims Operations Analyst will define business requirements and workflows, gather necessary approvals, and work with business operations or IT to implement and test solutions. In addition, they will support research and perform root cause analysis for claims quality remediation. They will create requirements, complete cost-benefit analysis, and propose solutions; support the implementation of new processes, technology and workflows impacting claim adjudications and facilitate claims process documentation (e.g., standard operating procedures, workflows).

Qualifications

• Bachelor’s degree (BA/BS) in business, health care, or related field and three (3) years experience in a Third Party Administrator (TPA), health plan, or health insurer supporting operations as an analyst.
• In-depth knowledge of health care claims processing technology & processes (e.g., claims processing systems, plan design, workflows, work queues, robotic automation, and standard operating processes).
• Six Sigma belt, agile or project management experience or certification, preferred.
• Advanced skills with workflow software (e.g., VISIO), creating presentations, or analyzing data using excel or other tools is a plus.
• Excellent written and oral communication skills to communicate effectively with senior leaders.
• Strong attention to detail and the ability to analyze and document complex business processes.
• Excellent planning and organizational skills.
• Analytical and problem-solving skills.
• Ability to interpret business needs and translate those needs to requirements.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties And Responsibilities

Claims Department Support

• Review the performance of vendors supporting the claim function, including monitoring the performance of EDI transactions and working with the business to troubleshoot errors and rejections from vendors and network partners.
• Evaluate the effectiveness of claims processing, quality assurance processes, and payment integrity programs through data and reports.
• Analyze data to generate KPI and dashboard metrics and reports at required intervals for claims leadership, claims staff, and other key individuals.
• Plan and implement user acceptance testing, including documentation, verification, and updates.
• Collaborate with other business areas to monitor cross-department workflow and hand-off, identifying areas of waste, inefficiencies, or errors.
• Support Claims leadership in root cause analysis of claim deficiencies and recommend solutions.

Process Improvement

• Analyze and assist with process improvement activities and the identification of efficient and effective methods of business operations, including manual processes and system automation, auto-adjudication, workflow queue rules, and claim edits.
• Collaborate with Claim Operations & IT leadership for system, process, and automation initiatives. Activities may include project management, process design and implementation, and post-implementation data and process analysis.
• Participate in initiatives with Claims and Operational leadership to identify critical business opportunities that transform existing processes to drive increased efficiencies to the claims end-to-end process flow.
• Build requirements and work with responsible areas (technology, plan build, provider) to implement process improvement initiatives or new requirements.

Process Documentation

• Create and maintain department workflows for all key processes from start to finish.
• Develop and maintain the Claims department operational process changes and updates, including SOPs, workflow diagrams, and job aids.
• Support the migration and ongoing maintenance of all claims documentation and SOPs on the department SharePoint site.
• Collaborate with subject matter experts, department leadership, and the training team to develop and obtain approval on process documents.
• Develop and manage the annual operational process document review.

Other

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.