Operations Reporting and Data Analyst - USA, Boston MA - $55,000 - $70,000

Operations Reporting and Data Analyst

USA, Boston MA

$55,000 - $70,000

Job Description

This key role will be responsible for managing, tracking and analyzing operational metrics to drive process improvement throughout the Operations. The Operations Reporting and Performance Analyst is responsible for defining, managing, verifying, and reporting key quality KPIs/metrics for various aspects of the business. These Metrics will help drive business functions and identify key areas for process improvement. This position will coordinate data collection and reports of various operations function to ensure they are accurate and compliant with relevant law, regulations, process and procedures. Ideal candidates will maintain a broad knowledge of corporate OPL Claims Processing, Payment Integrity, Government Programs, regulations and regulatory guidelines for use in conducting Claims Inventory Management, Performance and Operational Improvement. Major focus on the role will include creation of data visualizations, reports, and dashboards for internal and external use.

Our Investment in You:

·        Full-time remote work

·        Competitive salaries

·        Excellent benefits

Key Functions/Responsibilities:

·        Review and manipulate data and reports from multiple sources.

·        Design and maintain databases, data reports, and dashboards for tracking and reporting of quality.

·        Develop functional and technical specifications for data extracts to be used for data analysis and reporting.

·        Collaborate closely with SQL Programmers to interpret, define, and document data extraction specifications.

·        Develop easy-to-understand charts, tables, and graph for diverse audiences.

·        Monitor and quickly address OPL claims and data issues as they arise; escalate issues and support resolution in collaboration with the Manager of Other Party Liability.

·        Incorporate quality improvement methods via all data dashboards and presentations

·        Collaborate with other departments in order to interpret and assess needs of data requests.

·        Ensure the quality and timeliness of assigned deliverables; manage multiple concurrent projects.

·        Detail oriented with an understanding of quality improvement processes and related data skills

·        Participate in the development and implementation of efficient and effective OPL methodology including test automation, processes, procedures, templates guidelines and tools.

·        Determine root cause for data quality and make recommendations for long-term solutions.

·        Develop and maintain quality assurance process and procedure documentation and job aids to ensure consistent findings and determinations

·        Assist in developing project plans and costs, including personnel and fiscal requirements to achieve defined objectives.

Must have:

·        Bachelor degree or higher

·        Experience with Medicare and Medicaid

·        Experience with data reporting and analytics

·        SQL

·        SAS

·        EXCEL

Experience:

·        Working knowledge of Healthcare Operations and Medicare and Medicaid Claims processing practices

·        Other Party Liability claims and Claims Audit quality improvement concepts, practices and procedures

·        Experience with data reporting and analytics

·        5+ years in an HMO or other managed care setting, with experience on Medicare products such as a Medicare Advantage Plan, SCO or Duals Plan a plus

·        Project management

·        Prior experience within an HMO, PPO or other health plan

·        Prior experience within a Medicare Advantage, FFS, or other, organization and/or a Medicaid managed care organization

·        Prior experience evaluating and managing vendor quality

Certification or Conditions of Employment:

·        Pre-employment background check

·        2 doses of COVID vaccine

Competencies, Skills, and Attributes:

·        Knowledge of Medicare regulations.

·        Effective collaborative and proven process improvement skills. Helps to facilitate process improvement by engaging appropriate resources in issue identification and resolution.

·        Demonstrated ability to successfully plan, organize and manage projects.

·        Demonstrates strong organization skills and ability to work in a rapidly changing environment.

·        Strong oral and written communication skills; ability to interact within all levels of the organization.

·        A strong working knowledge of Microsoft Office products.

·        Familiarity with government programs such as Medicare and/or Medicaid.

·        Claims or other experience using industry standard coding.

·        Experience applying analytical results to decision-making.

·        Excellent team player with strong leadership skills.

·        Must be able to effectively manage activities across multiple departments.

·        Requires the capacity to clearly communicate complex issues and problems and escalate effectively.

·        Detail oriented, excellent writing, proof reading and editing skills required.

·        Ability to work independently and collaboratively, manage multiple projects and meet scheduled deadlines.

Working Conditions and Physical Effort:

·        Regular and reliable attendance is an essential function of the position.

·        Work is normally performed in a typical interior/office work environment.

·        No or very limited physical effort required. No or very limited exposure to physical risk.

Payment Policy Manager - USA, Remote - $95,000 - $105,000

Payment Policy Manager

USA, Remote

$95,000 - $105,000

Job Description

It’s an exciting time to join our company, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Payment Policy Manager is responsible for managing cross-departmental implementation of changes to payment and billing policies as necessary due to regulatory changes, contractual changes, or as a result of claims data findings. The Payment Policy Manager will collaborate with internal departments to define requirements and to document those requirements sufficiently to ensure accurate implementation of payment rules within the Plan’s adjudication system, including the claim editing system, iCES. The Payment Policy Manager will also review current payment policies and compare them to those used by competitors, state regulatory agencies, and CMS to evaluate and recommend changes, and upon approval incorporate such changes into materials. As directed by the department manager, he/she will project manage regulatory changes that impact payment methods or rates, and help drive analytics to support decision-making. Additional specific duties and responsibilities include:

Our Investment in You:

·        Full-time remote work

·        Competitive salaries

·        Excellent benefits

Key Functions/Responsibilities:

·        Develops and maintains corporate payment policies, and works collaboratively with the Clinical Editing Manager to ensure consistency with the Plan’s adjudication system(s)

·        Monitors DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and upcoming changes. Determines the scope and impact of the change on Plan operations and seek to implement changes as necessary

·        Staffs and participates in various work groups and committees to support payment policies and provides input into processes and workflows reliant on payment policy outcomes

·        Serves as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, DHHS and EOHHS fee schedules; and (2) regulatory issues. Determines the scope and impact of the information/issues and take appropriate action

·        Collaborates with Public Partnerships, Contracting, Medical Economics, Provider Relations, Benefit Administration, Business Configuration, and Provider Audit/OPL to determine the impact of implementing recommended policy changes

·        Develops project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from the Payment Policy Committee; and subsequently ensure successful completion of change

·        Serves as the company’s research specialist regarding Medicare and Medicaid payment policies.

·        Serves on the Operational Excellence Committee to ensure a consistent understanding of operational changes as they relate to payment policies and their downstream impact within the Claims department

·        Submits recommendations to the Payment Policy Committee and supports Committee efforts through subgroups and individually as needed

·        Collaborates with stakeholder departments to develop and maintain a database to serve a centralized location to store payment methodology information.

·        Researches, identifies and proposes opportunities for medical cost savings, improves claim auto adjudication rate and payment accuracy

Education:

·        Bachelor’s Degree in a related field or the equivalent combination of training and experience

Education Preferred/Desirable:

·        Master’s Degree or graduate work in a related field preferred

·        Coding Certification for Payers (CPC-P) preferred

·        AHIMA or other nationally recognized Coding Certification preferred

Experience:

·        6 or more years experience in a fast paced, managed healthcare environment is required.

·        6 or more years direct work in claims processing, payment policy, or contracting.

·        Extensive background of ICD-9 and CPT coding principles

·        Extensive knowledge of medical claim editing (NCCI, etc.)

·        Experience working with industry standard methods of payment including DRG, APC, RVU, etc.

·        Experience working with Medicaid, Medicare and commercial coding rules/ regulatory requirements.

Experience Preferred/Desirable:

·        Medical chart auditing

Competencies, Skills, and Attributes:

·        Demonstrated proficiency in coding and knowledge of the requirements of industry standards such as Medicare and/or Managed care regulations required.

·        Strong understanding of HIPAA Guidelines

·        Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.

·        Expertise utilizing Microsoft Office products, including Project and PowerPoint

·        Knowledge of OptumInsight iCES product, or similar claims editing system