ABOUT THE OPPORTUNITY:
Hiring Range: 59,500 – 65,000
The Sr. Healthcare Coordination of Benefits (COB) Data Mining Analyst is responsible for objectively and accurately completing conducting audit review and analysis on assigned client inventory, while maintaining high quality work output and successfully meeting productivity and recovery goals. This position makes identifies trends and makes determinations based subject matter expertise and strong analytical while leveraging audit tools and resources available. Communicates and supports the identification of additional data mining opportunities and participates in development of ideas as necessary. Able to contribute to resolution of more complex issues or client requirements and may supporting training and guidance to other Data Mining Analysts.
Key Responsibilities
- Conducts COB investigations and associated claims reviews and determines if claims are appropriately paid in accordance with COB rules, commercial billing guidelines and contracts, CMS regulations, and applicable laws and policies.
- Documents findings within audit tracking system and maintains thorough and objective documentation of findings.
- Provides support to client business processes related to claim recovery.
- Investigates, researches, and analyzes claims data, applying knowledge of medical or pharmacy policy to determine proper order of benefits with other payers, both Medicare and commercial.
- Creates narrative rationale to correspond with audit determinations.
- Meets and achieves assigned revenue goals and assigned metrics.
- As needed, supports findings during the appeals process.
- Serves as a senior claims payment resource; provides claims and reimbursement expertise, and guidance to the team.
- Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse.
- Monitors, tracks, and reports on all work conducted.
- Consults with our clients, data analysts, other claims payment resources and contractors as necessary.
- Maintains current in-depth knowledge of changes in technology, practice and regulatory issues that may affect our clients.
- Proactively contributes to process improvement activities and sets positive example for group participation and takes ownership in improvement initiatives.
- Actively contributes in quality assurance functions, development of member investigation guidelines and training.
- Proactively identifies and recommends opportunities for cost savings and improving outcomes.
- Serves as positive role model and example for other Analysts.
- May support training and guidance to other Analysts.
- Complies with company policies, processes, and procedures.
- Successfully completes, retains, applies and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position.
- Demonstrates Performant core values in performance of job duties and all interactions.
- Performs other duties as assigned
Knowledge, Skills and Abilities Needed
- Coordination of benefits, medical claims processing, and reimbursement subject matter expertise.
- Depth of knowledge of commercial insurance programs (including billing guidelines and contracts), CMS, regulations and applicable laws and policies.
- Demonstrated ability to apply breadth and depth of applicable business and industry knowledge to developing approaches to customer data mining opportunities as well as continuous improvement initiatives.
- Strong analytical skills.
- Ability to be flexible and seizes the opportunity to cross train.
- Ability to maintain high quality work while meeting deadlines, revenue goals, and performance metrics.
- Excellent organizational, interpersonal and communication skills
- Demonstrated ability to resolve complex problems.
- Ability to serve as a positive role model to more junior staff members.
- Demonstrated ability to train and support team members with less experience with positive interaction and results.
- Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
- Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.
- Acute sense of professionalism and confidentiality.
- Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel).
- Intermediate to advanced level of proficiency with Microsoft Excel, Word, and Access.
- Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment.
Required and Preferred Qualifications
- Bachelor’s degree or an equivalent level of competence obtained through experience, education and/or training.
- 8+ years of experience in the health care industry in eligibility or claims analyst type of function.
- 5+ years of experience with clearing houses/claims processing systems (e.g. UNET, COSMOS, NDB, TOPS, FACETS, AMYSIS, MHS, etc.)
- 5+ years working with large volumes of membership or eligibility data.
- Previous COB claims recovery experience required
- Experience with CMS shared data files and CAQH files preferred
- Employment VISA Sponsorship is not available for this position