Business Analyst, Sr. (Claims)

Business Analyst, Sr. (Claims)

CalOptima

CalOptima Health is seeking a highly motivated an experienced Business Analyst Sr (Claims) to join our team. The Business Analyst Sr (Claims) will be responsible for providing subject matter expertise in handling complex inquiries, claims adjudication error analyses, user acceptance testing coordination and new Facets logic training. The incumbent will support staff on issues related to Medi-Cal and Medicare, claims, benefits, pricing, payments and billing guidelines and rules. The incumbent will handle regulatory claims or projects, including interpretation of new All Plan Letters (APL) or MedLearns from Centers for Medicare & Medicaid Services (CMS), research benefits, pricing and coordinate configuration changes with Information Technology Services (ITS). The incumbent will serve as a claims subject matter expert (SME) for all CalOptima Health's departments, assess the impact of changes and provide guidance to the Claims Administration department.

Position Information:

• Department: Claims Administration
• Salary Grade: 311 - $77,863 - $124,581 ($37.43 - $59.8947)
• Work Arrangement: Full Telework
  
  **This position is eligible for telework in California.**

Duties & Responsibilities:

• 95% - Program Support
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Provides guidance and supports department staff with escalated issues and inquiries.
  • Leads and manages multiple concurrent projects and workflow for completion in a thorough and timely manner.
  • Analyzes APLs, MedLearn notices and Medi-Cal monthly bulletins to identify potential impact on the Claims Administration department.
  • Implements benefits or processes changes that impact system configuration due to federal and state notices.
  • Conducts research, documents findings, works with internal and external SMEs to formulate conclusions or potential solutions and prepares concise reports, presentations and other documentation to present to management.
  • Participates in cross departmental program implementation workgroups and discussions.
  • Identifies training and assists developing of desktop procedures and policies for the Medi-Cal and Medicare lines of business impacted by system and/or regulatory changes.
  • Performs ad-hoc analysis and reports, researches and provides summary of claims cases to various departments and creates or updates document processes and procedures.
  • Serves as the SME for all lines of business within the Claims Administration department and for end-to-end claims adjudication/processing.
  • Performs system research and testing to ensure regulatory, coding, contract updates and configuration changes are producing expected results. Ensures documentation accurately reflects the status of changes and outstanding issues identified during testing and communicates to the Claims Administration team.
  • Researches and solves complex claim issues and project challenges within the Claims Administration department.
  • Trains staff regarding system enhancements or changes, including process deficiencies identified from claims look-back analysis and User Acceptance Testing (UAT) testing.
  • Provides analytical support and technical expertise on requests for information from executives, directors and other staff regarding claims.
  • Works collaboratively with Claims Administration leadership and other internal departments to identify process improvement opportunities.
    
    
• 5% - Completes other projects and duties as assigned.

Minimum Qualifications:

• Bachelor's degree in business administration, health care administration, health services or related field PLUS 3 years of experience in claims, managed care benefits and operational protocol in the health care industry required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
  
• 3 years of experience in Medi-Cal managed care or Medicare Advantage required.

Preferred Qualifications:

• Direct or indirect experience with health care benefits configuration.
  
• Perform user acceptance testing health care benefits.
  
• Experience participating in cross functional work groups.

Required Licensure / Certifications:

• N/A

Knowledge & Abilities:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

About CalOptima Health:
CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About our Benefits & Wellness options:
At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the 2025 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is March 21, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.


To apply, please visit: https://jobs.caloptima.org/jobs/business-analyst-sr-claims-505-city-parkway-west-california-united-states







Copyright 2024 Jobelephant.com Inc. All rights reserved.

Posted by the FREE value-added recruitment advertising agency

jeid-e59c72408bff7343b0ab6909b5d53cce

• 

• CalOptima

Show more