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Provides subject matter expertise to departmental and corporate projects, by pulling data or creating scenarios needed for testing, validation, and root cause analysis on all types of claims, adjustments, for enhancements, updates, benefits and pricing as to impacts and resolutions. Ensure accuracy and understanding of operational processes to identify true end to end testing for optimal results.
Acts as Claims Department subject matter expert on departmental and corporate projects. Supports business definition and testing efforts, attends project meetings, and provides internal and external status reports.
Works with management and associates to document current business and workflow processes and collaborates in identifying, defining and documenting process improvement options and alternatives.
Prepares detail and summary level reports including written interpretation of analytic results for senior management.
Analyzes and trends claims issues, performs true root cause analysis and determines next steps for resolution and process improvement.
Researches issues, compiles feedback and drafts corresponding business requirements documents and business decision documents as needed.
Participates on conference calls with supervisor/manager/director other departments to provide project status, communicate changes in processes, and issue resolution.
Communicates test findings in a structured report format.
Build strong cross functional relationships that can be leveraged to understand issues that would not be in the sample size.
Escalate issues when on issue results in multiple discrepancies.
Assist supervisor, manager, and/or director with projects and problem resolution as required.
Runs and analyzes ad-hoc reports.
Formulates and applies analytical reports using the company's database to develop and interpret information that assists in developing test cases.
Tests validity of data using related software, service, manual calculations, or products. Frequently concentrates on collecting and analyzing data and developing test case scenarios both positive and negative.
Recommends processes or updates to current workflow as a result of research or analysis.
Provides assistance and support as needed to develop training material on new updates and enhancements.
Responsible for special projects that require analytical skills, forward-thinking whereby data is analyzed from different angles to think of the unknown, test the process.
Track and follow-up on all assigned high-level discrepancies, utilizing systems and procedures.
Maintain a high standard of data integrity, including systems and reports.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred A Bachelor's Degree in a related field or equivalent directly related experience
Preferred 5 years of experience in practical work within a healthcare organization
Required 3 years of experience in claims processing with a solid understanding of internal company claims functions
Advanced Knowledge of healthcare delivery Strong functional knowledge and broad multifunctional knowledge of healthcare delivery
Advanced Demonstrated organizational skills Demonstrated organizational skills with the ability to prioritize, coordinate multiple tasks, and work independently
Advanced Ability to multi-task
Advanced Ability to work independently
Advanced Demonstrated analytical skills
Advanced Demonstrated problem solving skills
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Advanced Ability to effectively present information and respond to questions from peers and management Strong analytical and problem solving skills
Licenses and Certifications: A license in one of the following is required: Technical Skills:
Required Intermediate Microsoft Word
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Project
Required Intermediate Microsoft Visio
Preferred Intermediate Microsoft Access
Required Intermediate Other Knowledge of Perot / Peradigm system
Required Intermediate Other Thorough knowledge of WellCare claims processing environment and procedures
Preferred Intermediate Other Knowledge of Legacy and Intelliclaim systems / processes