Lead Analyst COB PI Recovery 8684

<strong>At Emergent Holdings, we&rsquo;re creating an innovative environment where our employees belong authentically, contribute meaningfully, and thrive intentionally &mdash; both personally and professionally.</strong>

Southfield, USA

Emergent Holdings

<p class="p1"><strong>Emergent Holdings is driven by a singular goal &mdash; improving the health and safety of our customers and our communities. How do we do that? We create innovative insurance products, technology solutions, and services to support our key stakeholders &mdash; individuals, employers, providers, and strategic partners &mdash; improving the health and safety of the people and places we serve.</strong></p> https://emergentholdingsinc.com/

keywords: leadership,analysis,execute,support,research,performance,leadership,medical,training,experience,knowledge,analysis,performance,duty,write


Competitive Compensation and Benefits Package

Overview: Applies analytical and leadership skills to manage workflow, track, and report operational performance for medical claim overpayment recovery activities. Lead the implementation of new processes and enhancements to improve performance and quality. Execute control validation oversight and analyze data related to medical claim overpayment recovery/avoidance initiatives Utilize strong CMS and Medicare Advantage knowledge to train, coach, and provide feedback on team performance. This position will serve as the lead for workflow coordination, data analytics, and inventory management. This position reports to the Supervisor- Payment Integrity/COB &amp; Recoveries
Responsibilities: <ul> <li>Establish and manage workflow. Monitor, track, and report medical claim overpayment activities. Ensure timeliness is met and expected outcomes achieved.</li> <li>Lead the implementation of new processes and policy requirements.</li> <li>Lead the identification of process improvement opportunities. Identify barriers and lead the development of solutions.</li> <li>Support control validation oversight and analyze data to ensure quality and maintain compliance with CMS requirements and BCBSM MA policies.</li> <li>Support vendor oversight and operations for contracted services.</li> <li>Train, coach, and mentor team members. Provide feedback on team performance.</li> <li>Perform data reconciliation.</li> <li>Develop and consistently apply audit criteria to medical claims.</li> <li>Research and resolve complex inquiries.</li> <li>Execute department functions as needed.</li> <li>Serve as a subject matter expert regarding medical claim overpayment recovery/avoidance initiatives&nbsp;</li> <li>Represent the department on cross departmental work groups and committees.</li> <li>Assist leadership in analyzing data and reporting findings.</li> <li>Perform other related duties as assigned.</li> </ul> <p><strong>ADDITIONAL DEPARTMENT JOB DUTIES</strong></p> <ul> <li>Research and validate identified claim overpayments.</li> <li>Support audit concept management process.</li> <li>Support the implementation of claim overpayment recovery and avoidance initiatives</li> </ul> <p><strong>ADDITIONAL DEPARTMENT REQUIREMENTS</strong></p> <ul> <li>Strong working knowledge of claims operations including Medicare billing and reimbursement policy.</li> <li>Working knowledge of Microsoft Access, other Microsoft office applications, and related software programs.</li> </ul> <p><strong>ADDITIONAL DEPARTMENT PREFERENCES</strong></p> <ul> <li>Medicare professional and facility claim processing experience and/or auditing highly desired.</li> <li>Medicare Advantage plan operations experience is preferred.&nbsp;</li> </ul>
Requirements: <p><strong>EDUCATION AND/OR EXPERIENCE</strong></p> <ul> <li>Bachelor's degree in related field required or equivalent experience including Part C plan operations.</li> <li>Four (4) to seven (7) years&rsquo; experience in related field.</li> <li>Medicare Advantage plan operation experience is preferred.</li> <li>Ika claims system experience is desired.</li> <li>Reporting and data analytic experience preferably with medical paid claims.</li> <li>Prior experience auditing claim outcomes.</li> <li>Prior experience managing workflows</li> </ul> <p><strong>QUALIFICATIONS</strong></p> <p>To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p> <p><strong>OTHER SKILLS AND ABILITIES</strong></p> <ul> <li>Knowledge of Medicare claim billing and reimbursement policy claim industry standards, and medical claim operations. Familiarity with CMS guidance with respect to MA plan operations is preferred.</li> <li>Ability to research and apply Medicare payment policy, claim industry standards, and CMS regulations related to MA plans.</li> <li>Strong organizational, problem solving, verbal and written communication skills.</li> <li>Strong analytical and reporting skills.</li> <li>Ability to work independently, within a team environment and with multiple priorities.</li> <li>High level of proficiency in use of existing software packages (Access, Microsoft Word, Excel, Outlook, etc.).</li> <li>Ability to train and coach.</li> <li>Ability to lead the implementation of new processes, workflows, and enhance existing operations.</li> <li>Ability to work closely with the technical support team in understanding and resolving systems issues.</li> <li>Ability to develop, implement, and monitor policies and procedures.</li> <li>Ability to write in a clear, concise and grammatically correct manner and be able to translate complex requirements into language understandable by the general public.</li> <li>Ability to manage and reconcile data</li> <li>Ability to monitor inventory, performance, and influence outcomes</li> <li>Ability to maintain quality thresholds and resolve root cause issues</li> </ul> <p><strong>OTHER REQUIREMENTS</strong></p> <p><strong>LANGUAGE SKILLS</strong></p> <p>Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, vendors, and the general public.</p> <p><strong>MATHEMATICAL SKILLS</strong></p> <p>Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.</p> <p><strong>REASONING ABILITY</strong></p> <p>Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.</p> <p><strong>PHYSICAL DEMANDS</strong></p> <p>The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, and ability to adjust focus.</p> <p><strong>WORK ENVIRONMENT</strong></p> <p>The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to outside weather conditions. The noise level in the work environment is usually very quiet.</p> <p><strong>ADDITIONAL INFORMATION</strong></p> <p>The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.</p>