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 examining and managing processes for behavioral health Medi-Cal electronic (837) claims submitted by contracted service providers to the County of Santa Clara. Responsibilities also include reviewing claim documents, managing automated rejections, following up with Technology Services and Solutions (TSS) for any issues, ensuring smooth transitions of files and communications, adhering to claims processing rules, confirming provider reimbursement rates, obtaining input from BHSD Utilization Management departments, maintaining daily logs, reporting technical issues, participating in status and planning meetings, monitoring 837 batch files, coordinating with BHSD to respond to contract provider claims denial reasons, coordinating with Finance to ensure communication, updating Netsmart with CARC and RARC descriptions, and updating Concurrent Procedure Terminology (CPT) and cross-walk of coding.

Required skills and abilities include being 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, utilizing 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, and 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, experience with processing 837 claims, 835 EOB, and state payment processing, and 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.