Payment Cycle Analyst III

Job Summary Payment Cycle Analyst III is responsible for conducting both systemic and targeted analysis to identify reimbursement errors and to determine root cause. As well as collaborating with Configuration, Configuration UAT, Enterprise UAT, IT Claims, and Payment Cycle Team members to ensure test scripts are comprehensive. Essential Functions Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members. Research and provide recommendations to the Reimbursement Committee for reimbursement of services. Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates. Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders. Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties. Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events. Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements. Identify test result outputs and Claim SOPs that need to be modified or created to support new or changed business requirements. Build library of re‑usable tests plans & scripts to support the Market. Document the status of test results and gaps in testing for future improvements. Validate Impact Reports to ensure the criteria is consistent with story and universe of claims impacted by the changes. Approve UAT test scripts and test results prior to promoting changes to production and monitor post production results. Validate MCA Tests for expected results and communicate information to Reimbursement Analysts and HP Managers for provider notification. Conduct both systemic and targeted analysis to identify issues with testing and identify process changes for improvement. Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups. Education and Experience Bachelor's degree required. Equivalent years of relevant work experience may be accepted in lieu of required education. Five (5) years of health plan experience or equivalent experience with health plan operations and configuration required. Experience with user testing required. Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) preferred. Competencies, Knowledge and Skills Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio. Strong computer skills and abilities in Facets or equivalent claim payment system is preferred. Strong analytical skills with the ability to effectively communicate findings with the Leadership Team. Demonstrated understanding of claims operations, configuration, and testing related to managed care. Understanding of regression, unit, and user acceptance testing is required. Effective listening and critical thinking skills. Effective problem‑solving skills with attention to detail. Creative thinking to develop positive and negative test scenarios. Excellent written and verbal communication skills. Ability to work independently and within a team environment. Strong interpersonal skills and high level of professionalism. Ability to develop, prioritize, and accomplish goals. Understanding of the healthcare field and knowledge of Medicaid, Medicare, and Marketplace. Strong working knowledge of claims processing edits and logic. Familiar with CMS guidelines / HIPAA and Affordable Care Act. Licensure and Certification None required. Working Conditions General office environment; may be required to sit or stand for extended periods of time. Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required. Compensation Range $72,200.00 - $115,500.00. Equal Opportunity Employer CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #J-18808-Ljbffr CareSource