Claims Business Analyst
Posted on: 19 Jan 2021
Kapolei, HI
Job Description
Position Purpose:
Serve as the claims payment and claims configuration expert for plan and various departments to effectively identify and resolve claims issues. Act as the subject matter expert for the claims payment structure.
* Audit check run and send claims to the claims department for corrections. Collaborate with the claims department to price pended claims correctly. Identify authorization issues and trends and research for potential configuration related work process changes.
* Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication. Document, track and resolve all plan providers claims projects. Research the claims on various reports to determine if appropriate to move forward with recovery.
* Lead meetings with various departments to assign claim project priorities and monitor days in step processes to ensure the projects stay on track.
* Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems.
* Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation. Identify and analyze user requirements, procedures, and problems to improve existing processes.
Education/Experience:
High school diploma or equivalent experience. Bachelors degree in related field preferred. 3+ years of claims experience required. 0-2 years of business process analysis or data analysis experience preferred. 5+ years of claims processing, providing billing or provider relations experience pin managed care environment preferred.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
WellCare
Tampa, FL
WellCare Health Plans, Inc. provides government-sponsored managed care services. The company operates in three segments: Medicaid Health Plans, Medicare Health Plans, and Medicare Prescription Drug Plans (PDPs). The Medicaid Health Plans segment offers plans for beneficiaries of temporary assistance for needy families, supplemental security income, and aged blind and disabled residents; and other state-based programs, such as children's health insurance programs and long-term services and supports programs for qualifying families who are not eligible for Medicaid.
The Medicare Health Plans segment provides Medicare, a federal program that provides eligible persons aged 65 and over, as well as some disabled persons with a range of hospital, medical, and prescription drug benefits; Medicare Advantage, a Medicare’s managed care alternative to the original Medicare program, which offers individuals standard Medicare benefits directly through Centers for Medicare & Medicaid Services; and coordinated care plans that are administered through health maintenance organizations and require members to seek health care services and select a primary care physician from a network of health care providers.
The Medicare PDPs segment provides Medicare part D PDP plans to Medicare-eligible beneficiaries. Its PDP plans offer national in-network prescription drug coverage, including a preferred pharmacy network. As of December 31, 2018, the company served approximately 5.5 million members in the United States. WellCare Health Plans, Inc. was founded in 1985 and is headquartered in Tampa, Florida.
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IndustryHealthcare
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No. of Employees12, 000
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Website
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Jobs Posted917
