Payment Cycle Analyst III

Job Summary:

The Payment Cycle Analyst III is responsible for conducting both systemic and targeted analysis to identify reimbursement errors and to determine root cause. As well as collaborating with Configuration, Configuration UAT, Enterprise UAT, IT Claims, and Payment Cycle Team members to ensure test scripts are comprehensive.

Essential Functions:

• Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members
• Research and provide recommendations to the Reimbursement Committee for reimbursement of services
• Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
• Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders
• Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties
• Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events
• Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements
• Identify test result outputs and Claim SOPs that need to be modified or created to support new or changed business requirements
• Build library of re-usable tests plans & scripts to support the Market
• Document the status of test results and gaps in testing for future improvements
• Validate Impact Reports to ensure the criteria is consistent with story and universe of claims impacted by the changes
• Approve UAT test scripts and test results prior to promoting changes to production and monitor post production results
• Validate MCA Tests for expected results and communicate information to Reimbursement Analysts and HP Managers for provider notification
• Conduct both systemic and targeted analysis to identify issues with testing and identify process changes for improvement
• Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree or equivalent years of relevant work experience is required
• Minimum of five (5) years of health plan experience is required or equivalent experience with health plan operations and configuration
• Experience with user testing is required
• Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) is preferred

Competencies, Knowledge and Skills:

• Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio
• Strong computer skills and abilities in Facets or equivalent claim payment system is preferred
• Strong analytical skills with the ability to effectively communicate findings with the Leadership Team
• Demonstrated understanding of claims operations, configuration, and testing related to managed care
• Understanding of regression, unit, and user acceptance testing is required
• Effective listening and critical thinking skills
• Effective problem-solving skills with attention to detail
• Creative thinking to develop positive and negative test scenarios
• 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, Medicare, and Marketplace
• Strong working knowledge of claims processing edits and logic
• Familiar with CMS guidelines / HIPPA and Affordable Care Act

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource 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):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business