Claims Business Analyst

Role Description

As a Claims Business Analyst, you will be responsible for triaging operational issues and leading projects and tasks to completion. You will use your claims adjudication experience and TPA background to triage operational concerns, vendor issues, and related claims issues. Familiarity with Centivo’s claims systems (Javelina and HealthRules Payer) is preferred. You will coordinate with all business units and external vendors during client implementations and conversions to determine requirements. This role ensures seamless integration between internal and vendor systems to support client requirements and operational workflows. Additionally, you will lead key projects and tasks identified to improve efficiency of Centivo’s Claim team. This role will use data analytics and other tools to identify areas of improvement needed in the business, scope out the initiative, and then lead the project through to completion.

Responsibilities Include:

• Support the Centivo Claims Team with troubleshooting issues, identifying the root cause and magnitude, and then researching and recommending the best solution.
• Effectively work with end-users and operational partners to identify business needs and to ensure implementations meet business requirements and appropriately address prioritized needs.
• Develop and maintain advanced reporting, dashboards, KPI’s and business insights to support operational decision-making through measurement of performance and effectiveness of processes.
• Assist with creating Process Flows on new initiatives and existing processes as needed.
• Function as a liaison between business and technical resources to ensure people, processes, and solutions meet or exceed the needs of our Clients and Operational areas.
• Pull and analyze daily, weekly, and monthly operational reports to support Claims Operations, monitor team performance, identify trends, and provide actionable insights to leadership.
• Work with business partners to identify and articulate business requirements in each area. Facilitate brainstorming sessions to review solution options that will solve business needs.
• Assist and participate in the claims testing process for new technology, vendor, and processes.
• Proactively keep abreast of vendor enhancements as well as how they integrate with existing solutions.
• Collaborate with the Subject Matter Expert (SME) on all aspects of the functionality of the Claims systems and act as the primary liaison with the vendor for reported issues and enhancement requests.
• Work with the team on oversight of the implementation of claims platform upgrades and supporting technologies. This includes coordinating user acceptance testing with the operational leads.
• Proactively identify opportunities and recommend system solutions that increase automation, resolve system deficiencies, and enhance claims processing and reporting to meet and exceed business requirements.
• Participate in the assessment of new technologies, new vendors, and any system enhancements being contemplated.
• Participate in internal and external meetings for plan design, strategy, and setup.
• Query data or create reporting to support analysis of issues, trends or specific reporting needs for clients or providers related to claim performance.
• Performs other duties as deemed essential and necessary.

Qualifications

• Advanced problem-solving skills, with a track record of researching and resolving operational issues accurately and on time.
• Highly organized and able to work independently, using sound judgment to manage priorities and make decisions.
• Adapts to changes in the work environment; manages competing demands and deals effectively with frequent changes, delays, or unexpected events, including production schedule pressure.
• Builds strong working relationships and influences outcomes across cross-functional teams.
• Proficiency in Microsoft Office and other web-based software applications.
• Skilled in running queries and analyzing data to identify trends and issues.
• Excellent verbal and written communication skills — able to explain complex or technical information clearly, and to understand and interpret complex information from others, including reimbursement policy standards.

Requirements

• At least 5 years of experience within healthcare claims.
• 3 years of experience working as a Business Analyst.
• Prior experience with highly automated and integrated claim adjudication systems.
• Understanding of health insurance benefits administration in a self-funded environment.

Preferred Qualifications

• Experience working with El Dorado-Javelina or HealthRules Payer.
• Experience working at TPA.
• Experience with self-funded plans.
• Proficient in SQL, Tableau and JIRA.
• Intermediate to advanced proficiency in MS Excel.

Work Location

• Preference for Buffalo Office.
• Open to Remote.

Centivo Values

• Resilient – This is wicked hard. There is no easy button for healthcare affordability. Luckily, the mission makes it worth it and sustains us when things are tough. Being resilient ensures we don’t give up.
• Uncommon - The status quo stinks so we had to go out and build something better. We know the healthcare system. It isn't working for members, employers, and providers. So we're building it from scratch, from the ground up. Our focus is on making things better for them while also improving clinical results - which is bold and uncommon.
• Positive – We care about each other. It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it. Because of that, we make sure we give kudos freely and feedback with care. When our tank gets low, a team member is there to be a source of new energy. We celebrate together. We are supportive, generous, humble, and positive.