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Sr. Business Analyst, Medicare Advantage Operations

Company: Harvard Pilgrim Health Care Institute
Location: Canton
Posted on: May 16, 2022

Job Description:

Harvard Pilgrim Health Care is currently seeking a highly motivated individual to join our Medicare Advantage Operations team as a Sr Business Analyst. The Senior Business Analyst is responsible for Quarterly EOB production in accordance with CMS regulatory guidelines, development of queries and reports to address ad hoc and routine business needs, research, and resolution of assigned escalated claim issues and general support for the Stride Medicare Advantage Operations function.Job Description

  • Lead the production of the Quarterly EOB process with QA support from the Technical Program Manager to ensure timely issuance of QEOBs in accordance with CMS regulatory requirements. Ensures follow through and correction of any identified data issues.Serves as the Subject Matter Expert for QEOB production and accountable for resolution of escalated issues.
  • Interpret business needs to independently and efficiently develop Sequel queries and Excel analyses of enrollment, billing and claim data to address time sensitive ad hoc management and compliance requests.Prepare final reports with consideration of the intended audience.Maintain documentation of methodology and relevant back up information in shared department records.
  • Work collaboratively with the Medicare Payment Integrity Lead to support analysis of systemic claim issues to determine root causes of incorrect processing and assist with resolution, as assigned.
  • Research assigned escalated claims and facilitate resolution and provide recommendations for process improvements.Proactively communicate potential system configuration issues to designated staff for resolution.Submit tickets to contracted claim vendor to request reprocessing.Facilitate updates to ika system documentation.Maintain sufficient records of case documentation and rationale in accordance with department procedures to support future research needs.
  • Participate in the Configuration Workgroup and other claim resolution and system management forums, as assigned.Assists with maintenance of JIRA documentation for systemic escalated issues.
  • Work in collaboration with the Stride Technical Program Manager, Advantasure (ika) technical resources, Corporate Information Management and HPHC vendor relationship managers to support oversight of all ecosystem file transfer processes in production.Assist the Stride Technical Program Manager with issue resolution and documentation.
  • Support other Stride Medicare Advantage Operations departmental functions, as assigned.Requirements -EDUCATION, CERTIFICATION AND LICENSURE:
    • Bachelor's Degree in Business, Health Care Administration, Analytics, or related field. Master's Degree preferred. EXPERIENCE (minimum years required):
      • Demonstrated experience (5 to 7 years) knowledge of managed care industry, health insurance practices and analytics.Experience with Medicare Advantage and CMS regulated products preferred. -SKILL REQUIREMENTS:
        • Proficiency with Sequel as well as Microsoft Excel, PowerPoint, Word, and Visio.
        • Working knowledge of Medicare claim processing and general knowledge of payment regulatory guidelines and industry practices
        • Ability to independently assess situations efficiently, make decisions and initiate resolution; manage the details with accuracy along with the ability to understand how work products influence or impact the big picture.
        • Ability to work independently, manage multiple priorities and effectively prioritize tasks
        • Strong interpersonal listening, verbal, and written communication skills; approachable, problem-solving personality.
        • Resilient, collaborative, flexible, innovative.What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law. -About Us:Point32Health is a leading health and wellbeing organization, delivering an ever-better health care experience to everyone in our communities. Building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.At Point32Health, we're working to reshape the world of health care by pushing past the status quo and delivering even more to the diverse communities we serve: more innovation, more access, more support, and healthier lives. And we want people like you on our side to make it even better.This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.Req ID: R3891

Keywords: Harvard Pilgrim Health Care Institute, Boston , Sr. Business Analyst, Medicare Advantage Operations, Professions , Canton, Massachusetts

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