SCOPE OF ROLE

The Claims Analyst assists with oversight of claims processing, verifying information on submitted claims, reviewing the policy to determine which charges are eligible for reimbursement, auditing any vendor processed claims.  They ensure all business rules set by Bright Health Plan are followed by vendors and that payments are made according to CMS guidelines, Bright Contract and plan benefit designs. The Claims Analyst participates in audits, coordinating with Compliance and Legal to ensure Bright Health Plan provides all the requested data, navigate systems as needed during audit and provide any follow up requested by auditors.

ROLE RESPONSIBILITIES

The Claim Analyst job description is intended to point out major responsibilities within the role, but it is not limited to these items:

• Partner with Configuration, Provider Data, Network and vendors to ensure claims are paid to providers and members accurately
• Monitor policies and procedures for Bright Health with claims
• Monitor daily reporting distributed by vendors (claim reports, document aged reports)
• Provide recommendations on the design of claim payment system configuration
• Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support
• Handle adverse and politically difficult situations, as payment accuracy has a significant impact on the financial performance of the organization and our providers, processes related to claims processing, managed care negotiations along with directly impacting the financial performance of Bright Health Plan
• Read, interpret, and formulate complex computer system rules and managed care reimbursement payment methodologies including but not limited to CMS payment rules and requirements
• Other duties and responsibilities as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree in Business Administration or related field required.
• 3-5 years of experience in Enrollment, Premium Billing, Claims, Member and Provider Service, and Appeals at a health insurance company will be considered in lieu of a degree.
• 3-5 years of experience in commercial facility and professional pricing methodologies (DRG, case rate, per diem, % of billed, fee schedule, etc.) and application of CMS billing guidelines required.
• 3-5 years of health care systems and inter/intra-relationships specific to value-based contracting activities required.
• 3-5 years of complex managed care concepts/processes, and health insurance pricing and associated benefit design knowledge required.
• Intermediate or advanced Excel skills for data analysis required.

PROFESSIONAL COMPETENCIES

• Able to create and maintain strong working relationships.
• Complex problem-solving skills.
• Able to manage resources in a matrix environment, communicating and influencing effectively at all levels of the organization.
• Effective at vendor negotiations and relationship management.
• Broad knowledge of health insurance and services delivery and functions.
• In-depth knowledge of federal, state and CMS based requirements and the ability to develop, distribute and administer Medicare programs in a compliant manner.
• Success managing multiple initiatives and priorities simultaneously.
• Able to quantify impact and ROI of initiatives.
• Experience in government programs including Exchanges, Medicare and/or Medicaid.
• Experience with integrating health plan support services and other elements of operations in high-growth environment.
• Certified commercial medical billing coder a plus

BEHAVIORAL AND LEADERSHIP NORMS

• Bright Values: Lives the Bright Values.  Given the individual role in the organization, creates a culture of positivity within team. Leads by example.  Acts with quiet, calm determination. Effectively influences in team setting.
• Communication: Is an effective communicator. Internally, leads 1:1 and small groups of people in meetings. Capable of developing agenda, setting objectives, driving clarity of purpose and delivering the intended results. Can clearly articulate an inspiring goal/objective for each teammate and define success.
• Delivers Results: Is results oriented. Focuses on results, not effort, and is able to efficiently direct time and energy to achieving intended outcome.  Takes strategic company initiatives and translates them to implementable processes that drive outcomes. Achieves strong results within their functional area. Focuses on managing against a predetermined set of objectives and creates and follows process.
• Direct Management: May oversees a team of people who interact externally with members/brokers/vendors or who perform highly specialized work. Responsible for training new employees and developing existing employees. Translates corporate goals into actionable individual goals. Delivers thoughtful and constructive feedback to teams. Sets an example for employees. Manages up appropriately and knows how and when to escalate an issue or situation to more senior manager.
• Prioritization: Establishes priorities by looking to predetermined goals in the organization. Is capable of deciphering priorities for self and for others and focuses the group on what must be done today, and who must do what. Is flexible and agile and can quickly reset priorities within team with clarity of purpose.

WORK ENVIRONMENT

The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel may be required.