BCN Financial Analyst - PFA

<p>With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.</p>

Southfield, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />Learn more about your options as an external candidate. <a href="https://bcbsm.taleo.net/careersection/2/jobsearch.ftl?lang=en" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: professional,analysis,analysis,support,teamwork,prepare,performance,quality assurance,leadership,knowledge,experience,department requirements,degree,skills

Full-time

Competitive Total Compensation Package

Overview: Support specific unit within the department (for example reimbursement and audit, reimbursement and audit &ndash; government programs, reporting). Based on unit assignment may be responsible for preparation and analysis of monthly HMO Primary Care Group (PCG) financial statements and other paid claim reports for the BCN product lines, coordination with parent organization (BCBSM) to supply reports for settlement purposes or auditing of paid claims to ensure payments are made per contractual language and complicated reimbursement audits. Support Provider Affairs department by producing detailed ad-hoc reports to assist in management of PCG members or assist with other facility audits to ensure claims are paid at the contracted rate.
Responsibilities: <strong>PROVIDER REPORTING:</strong><br /> <ul> <li>Prepare and analyze monthly financial statements of assigned primary care groups; provide recommendations regarding financial performance.</li> <li>Interact with provider consultants to assist in explanations regarding monthly provider statements.</li> <li>Meet with PCG business administrators/medical directors as necessary.</li> <li>Prepare and analyze annual provider settlement for assigned PCG groups; develop issues list and other supporting documentation.</li> <li>Work with IT on required modifications to production reports.</li> <li>Detect errors in claim payments and participate in resolution.</li> <li>Represent department on corporate workgroups and committees; cross train within department. Other duties may be assigned.</li> </ul> <strong>REIMBURSEMENT AND AUDIT:</strong><br /> <ul> <li>Analyze and report to BCBSM PHA hospital payments for discounted or unique arrangements to ensure accurate settlement of claims.</li> <li>Analyze and audit claim payments and payment mechanisms produced by the Facets claims system.</li> <li>Perform fee schedule impact analysis for modeling purposes and decision making; re-price claims due to retro-active pricing updates.</li> <li>Analyze, research, develop and implement new reimbursement methods.</li> <li>Assist in User Acceptance Testing of new reimbursements to assure appropriate payouts are made.</li> <li>Represent department on corporate workgroups and meetings.</li> <li>Other duties may be assigned.</li> </ul> <strong>REIMBURSEMENT AND AUDIT- GOVERNMENT PROGRAMS:</strong><br /> <ul> <li>Act as lead team member to ensure that all fee schedules and reimbursement methods are current with changes at CMS.</li> <li>Perform routine monitoring of fees integrated with BCNA&rsquo;s claim processing system to ensure compliance and accurate payment of claims.</li> <li>Develop annual plan of pro-active audits and complete audits required due to claim inquiries and compliance activities.</li> <li>Assist other team members in the auditing of paid claims to ensure proper payment according to the provider contract.</li> <li>Represent department on workgroups related to pricing, benefits, authorization and other CMS regulations and guidelines.</li> <li>Develop and/or assist in communication to providers or internal customers related to reimbursement policies.</li> <li>Participate and assist other team members with User Acceptance Testing of pricing/reimbursement changes made in Facets.</li> <li>Ensure that test conditions and documentation is complete and that the testing is completed in accordance with pre-defined Facets change release schedules.</li> <li>Resolve both internal and external customer inquiries related to claims, benefit, authorization and CMS regulations and guidelines.</li> <li>Act as back-up to other team members as required.</li> <li>Other duties may be assigned.</li> </ul>
Requirements: <strong>Department Summary / Preferences:</strong><br /> <ul> <li>Primarily focused on Provider Reporting.</li> </ul> PROVIDER REPORTING:<br /> <ul> <li>Prepare and analyze monthly financial statements of assigned primary care groups; provide recommendations regarding financial performance. Interact with provider consultants to assist in explanations regarding monthly provider statement.</li> <li>Strong Excel and Access skills are required. Healthcare experience is a plus.</li> </ul> <strong>Provider Reporting:</strong><br /> <ul> <li>Bachelor's Degree in Business Administration, Finance, Accounting, Computer Science or related field.</li> <li>Two (2) years systems analyses experience.</li> <li>One (1) year database management software and PC experience.</li> <li>Ability to perform detailed financial analysis, complex pricing, system research/analysis, reconciliation, provide solutions and/or develop audit reports.</li> <li>High degree of complex evaluative, analysis and problem solving.</li> <li>Advanced knowledge of Microsoft Office Suite software (Access, Excel, and Word) required Business Object and Facets preferred.</li> <li>Excellent verbal and written communication skills</li> <li>Knowledge of HMO procedures preferred.</li> <li>Other skills and abilities may be required.</li> <li>Thorough understanding of managed care physician provider reimbursement and risk funding arrangements preferred.</li> <li>Knowledge of funding arrangements between BCN and IPAs preferred.</li> </ul> <strong>Reimbursement and Audit:</strong><br /> <ul> <li>Bachelor's Degree in Business Administration, Finance, Accounting, Computer Science or related field.</li> <li>Two (2) years systems analyses experience required which includes one year (1) year of medical claim systems configuration and/or pricing analyses.</li> <li>One (1) year experience using diagnosis and procedure coding systems (for example CPT, MUPC, HCPCS and ICD-9) with regard to hospital or medical claims billing and processing.</li> <li>One (1) year database management software and PC experience.</li> <li>Ability to perform detailed financial analysis, complex pricing, system research/analysis, reconciliation, provide solutions and/or develop audit reports.</li> <li>High degree of complex evaluative, analysis and problem solving.</li> <li>Advanced knowledge of Microsoft Office Suite software (Access, Excel, and Word) required Business Object and Facets preferred.</li> <li>Excellent verbal and written communication skills.</li> <li>Knowledge of HMO procedures preferred.</li> <li>Other skills and abilities may be required.</li> <li>Thorough understanding of managed care physician provider reimbursement and risk funding arrangements preferred.</li> <li>Detailed knowledge of claims, pricing, benefits and provider mainframe computer systems required, including BCN mainframe claims subsystem (Facets) interaction preferred.</li> <li>Knowledge of funding arrangements between BCN and IPAs preferred.</li> <li>Demonstrated knowledge of claim processing system analysis and configuration preferred.</li> </ul> <strong>REIMBURSEMENT AND AUDIT - GOVERNMENT PROGRAMS:</strong><br /> <ul> <li>Bachelor's Degree in Business Administration, Finance, Accounting, Computer Science or related field.</li> <li>Two (2) years experience using diagnosis and procedure coding systems (for example CPT, MUPC, HCPS and ICD-9) with regard to hospital or Medicare claims billing and processing.</li> <li>Three (3) years experience with claim payment/reimbursement methodology and related investigation.</li> <li>One (1) year database management software and PC experience.</li> <li>Ability to perform detailed financial analysis, complex pricing, system research/analysis, reconciliation, provide solutions and/or develop audit reports.</li> <li>High degree of complex evaluative, analysis and problem solving.</li> <li>Advanced knowledge of Microsoft Office Suite software (Access, Excel, and Word) required Business Object and Facets preferred.</li> <li>Excellent verbal and written communication skills.</li> <li>Knowledge of HMO procedures preferred.</li> <li>Other skills and abilities may be required.</li> <li>Thorough knowledge of health plan, Medicare or government program provider reimbursement.</li> <li>Detailed knowledge of claims, pricing, benefits and provider mainframe computer systems required, including BCN mainframe claims subsystem (Facets) interaction preferred.</li> <li>Demonstrated knowledge of claim processing system analysis and configuration preferred.</li> </ul> <em>All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.</em>