Business Systems Analyst

Business Systems Analyst

The County is searching for two (2) resources to manage the intake and adjudication for Behavioral Health Services Department (BHSD) contract service providers.

Specific tasks include:

• Examines and manages processes for behavioral health Medi-Cal electronic (837) claims submitted by contracted service providers to the County of Santa Clara.
• Reviews claim documents, including electronic claims (837), for required data elements for eligibility, benefits, authorization, and appropriate medical coding.
• Manages automated rejections that lack complete claim information.
• Follows up with Technology Services and Solutions (TSS), Finance and vendor for any issues with receiving 837 claim files from contract providers.
• Ensures smooth transitions of files and communications between BHSD, TSS, Finance, Patient Billing Services (PBS) and contractors.
• Is familiar with and adheres to all claims processing rules as outlined in CA title 28 for Medi-Cal.
• Ensures that all claims payments and denials are accurate and that the appropriate denial letter is issued to the provider or organization.
• Adheres to California State Department of Managed Care regulations and established timelines for examining and processing medical claims.
• Confirms provider reimbursement rates, in collaboration with the County of Santa Clara BHSD and makes necessary revisions to the Netsmart configuration with TSS.
• Obtains input from BHSD Utilization Management departments as necessary for making a claims decision.
• Maintains daily log of all activities, including number of claims processed and special projects completed.
• Informs assigned Manager on any irregularities in claims submitted, including potential fraud and abuse issues.
• Documents and assists assigned resources in training County staff hired to perform claims management and configuration maintenance.
• Performs various duties such as batching incoming claims, researching tracers, and returning claims to providers.
• Reports technical issues with the technology solutions used via County ticketing system and coordinates with TSS and solutions vendors to resolve technical issues.
• Participates in status and planning meetings as directed.
• Participates in additional roll-out of automated 837 claims processing with the County and contract providers.
• Monitors 837 batch files for common configuration errors correcting configuration with TSS, Finance and BHSD as directed and automating 837 batch processing as common errors resolved during implementation roll-out to contract providers.
• As requested, may monitor, on a frequency requested, state 835 payments to ensure error resolution coordinating with TSS and BHSD to identify and resolve errors.
• Coordinates with BHSD to respond to contract provider claims denial reasons.
• Coordinates with BHSD, Finance, PBS and TSS to ensure automation wherever possible to eliminate any manual processes.
• Coordinates with Finance to ensure communication, including electronic files for Explanation of Benefits (EOB) are being received by Finance.
• Updates Netsmart with CARC (CA State Claims Adjustment Reason Codes) and RARC (CA State Reimbursement Adjustment Reason Codes) descriptions for ease of understanding for state codes.
• Updates Concurrent Procedure Terminology (CPT) and crosswalk of coding as directed by Finance and/or PBS.
• Performs other file or table maintenance as directed by the Project Manager.
• Completes detailed Visio process flows and communicates with staff involved.
• Creates tip sheets for contract providers to understand denials.

Required skills and abilities include:

• Skilled and experienced with best practices, standards, methods and procedures of effective claims adjudication in the health care industry utilizing technology systems to automate processing.
• Ability to utilize modern office administrative practices and procedures including computer office applications, MS Suite for email, spreadsheets, presentations and documentation.
• Knowledge of Medi-Cal, Medicare and other insurance program regulations and managed care claims processing.
• Familiarity with Commercial insurance regulations in a managed care environment.
• Knowledge of medical terminology, CPT, ICD-9 Coding, and other available resource reference tools.
• Knowledge of automated health care claims processing systems.

Experience requirements include:

• 3-5 years of experience with Medi-Cal and other insurance program effective claims management and claims adjudication in the healthcare industry.
• Must have experience with processing 837 claims, 835 EOB, and state payment processing.
• Experience with automated healthcare claims processing systems with a preference for knowledge of Netsmart's Managed Services Organization (MSO) and California Practice Management (CalPM) modules.