The Business Analyst is responsible for the monitoring and/or processing of all corporate grievance and appeals, Medicaid recertification and Other Insurance (COB). This incumbent will also be responsible in the tracking of utilization management activities and ensuring operational processes are being followed, such as coverage determination, monitoring hospice, alternate level of care, ESRD status changes. In addition, provides support to the Member Rewards and Incentive Program as well as supporting other initiatives as directed by the Vice President of Operations.
The Business Analyst will alert the VP of any breakdown in processes and help make necessary changes to avoid future non-compliance or adverse situations. The individual works on various day-to-day operational tasks and interacts as needed with the VP and other Operational staff members.
Duties and Responsibilities:
- Conducts investigation of grievances and other issues thoroughly by interfacing with involved parties to get at an acceptable resolution. Prepare the Grievance Resolution Letter in accordance with regulatory requirements.
- Track and trend grievances and identifies barriers to customer satisfaction and recommends actions to address operational challenges.
- Tracks and monitors all Appeals received and ensures timely processing and compliance with all regulatory requirements. Acts as the Subject Matter Expert and provides the necessary support to ensure each case file is addressed appropriately. Performs ad hoc audits to assure appeals are processed within appropriate timeframes for both Part C and Part D appeals.
- Create/maintain a comprehensive database to track/monitor member status changes, such as member moving to Hospice, Alternate Level of Care, ESRD, etc., and assures Claims are being processed correctly.
- Track member Medicaid recertification process and interfaces with appropriate parties (Care Management, CCOs, HRA, LDSS, etc) to ensure timely recertification.
- Track and assist in the validation of “other insurance” information and work with appropriate parties to make the necessary changes.
- Assist in the monitoring of high-dollar claims and ensure timely responses are provided to allow for timely claim adjudication.
- Creates workflows depicting processes and documenting applicable policies and procedures. Ensures policies remain current and agreed upon processes are being followed.
- Assist in processing rewards involved with PHP’s Member Rewards and Incentive Programs.
- Assist in the mailing of monthly Provider Panel Reports, and All other duties as assigned.
- Bachelor’s Degree required.
- 2-4 years’ experience in a health care organization and relevant experience in areas of operations and/or systems required.
- Prior experience working in Grievance & Appeals or Claims Processing preferred.
- Strong organizational skills and attention to detail required.
- Ability to organize work, set and manage multiple priorities required.
- Effective verbal, written and interpersonal communication skills required.
- Excellent documentation, analytical and problem-solving skills required.
- Strong computer skills, including proficiency with Microsoft Word, Outlook and Excel required.
- Must be flexible in meeting the demands of all departmental operations.
- Candidate must possess maturity and ability to achieve results in a collaborative executive management environment.
Requirements of All Positions:
- All employees shall meet PHP’s Compliance and Privacy Regulations, and attend at a minimum of one (1) hour of Compliance and Privacy educational training annually;
- All employees shall master PHP’s Model of Care and complete all training requirements within the first thirty (30) days of employment and annually thereafter, or as required by state and federal regulations;
- All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
- Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
1. Improve health outcomes;
2. Prevent hospital readmission;
3. Improve patient safety and reduce medical errors, and
4. Provide wellness and health promotion activities.
Physical Demands and Work Environment:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel utilize objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl.
The employee must occasionally lift and/or move up to 25 pounds, and infrequently up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. The noise level in the work environment is usually moderate.
Equal Opportunity Employer