Senior Business Systems Analyst - Medicare - Kforce Inc.

Kforce has a client that is seeking a Senior Business Systems Analyst - Medicare in Huntington Beach, CA. Duties Include:

• Develop and implement databases, data collection systems, data analytics and other strategies that optimize statistical efficiency and quality
• Manages all business activities involving system development and implementation, provider, and hospital contract configuration, coding compliance and fee schedule implementation
• Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases
• Work collaboratively across the organization to address business needs, determine configuration changes needed and how the changes impact other areas
• Validate data to be housed on provider databases and ensure adherence to business and system requirements as it pertains to contracting, network management, and credentialing
• Perform Fee Schedule and Benefit QC to ensure the system is set up correctly before being released into production
• Audits loaded provider records for quality and financial accuracy and provides documented feedback
• Reviews current benefit and DOFR configurations and suggests improvement processes to ensure systems are working more efficiently and improve quality
• Troubleshoot system related issues and analyze business needs, determine necessary configuration, and develop test scenarios to ensure accurate and complete testing
• Generates Provider Related reports to facilitate and support Provider Services/Provider Problem Research and Resolution
• Generates and distributes Network Related Compliance/Regulatory/Accreditation reports
• Assists in configuration issues and loading of provider information, as needed
• Research and resolve claim/issues, pended claims and update system
• Supports Claims staff with complex claims
• Special Project as assigned

Requirements:

• Bachelor's degree preferred in Computer Science, Healthcare Administration, or related field required; Master's degree or equivalent preferred
• 3-5+ years of experience in configuration/benefits and/or medical claims processing
• Experience with bundled payment contracting or risk and capitation required
• Proficient in Microsoft Suite (Excel, PowerPoint, Project, Outlook, Word, Visio, etc.)
• Extensive experience in SQL
• Experience with the end-to-end claims processing
• Knowledge of medical terminology, ICD-10, CPT and HCPCS
• Understand all relevant payment methodologies, including but not limited to Medicare, RBRVS, DRG, APR-DRG, OPPS, Per Diems, Capitation, and Case Rates
• Strong analytical skills with the ability to collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy
• Understands and can construct financial responsibility tables and check for accuracy against Health Plan Documents
• Understands how to build/maintain Benefit Rules and Benefit Records (Detail Option Records)
• Understands how to translate Health Plan EOC's into system Benefit Tables
• Ability to manage and prioritize multiple tasks, promote teamwork and fact-based decision making
• Communication skills
• Ability to work independently and within a team environment
• Familiarity of the healthcare field
• Critical listening and thinking skills
• Training/teaching skills
• Decision making/problem solving skills
• Resiliency in a changing environment
• Demonstrated progression of leadership and responsibility
• Ability to work in a fast-paced, start-up culture
• Proven ability to build, develop, and lead strong teams of operators
• Ability to travel