Claims Configuration Jobs in Clover, SC (NOW HIRING)

We are looking for a Claims Business Analyst who will be the vital link between our information technology capacity and our business objectives by supporting and ensuring the successful completion of analytical, building, testing and deployment tasks of our software product’s features.

This Claims Business Analyst works collaboratively with the Director of Claims in supporting the department to deliver timely and accurate payment of claims and first call resolution . This role will also provide analysis related to the identification of improved claim system configuration and call flows that would positively impact quality performance , reduce claim inventory and improve the customer experience.

Responsibilities

• Assist in the development of key performance indicators related to claim processing and call center performance
• Use existing technology to automate work distribution, create and maintain department metric dashboards
• Generate and distribute weekly/monthly/quarterly departmental reports to management and staff
• Summarizes, creates, and distributes operational , claim data , and call center metric reports as needed.
• Ensures deliverables are completed on time; responds to changing project circumstances and communicates issues to project leadership.
• Identify trends in data, including those that were not necessarily being activity monitored, which may have an impact on departmental performance and/or impact timeliness and the customer experience . Communicate actionable findings and provide recommendations as appropriate to management.
• Work directly with managers and subject matter experts to refine and improve these tools for optimal efficiency and effectiveness.
• Responsible for creating data definitions, validating data, retrieving data from systems, merging data from multiple sources, participating or reviewing technical documentation, report configuration, and coordinates project efforts as directed in order to achieve desired results.
• Serves as a liaison to other department s (IS, Utilization Management, Provider Contracting, Provider Data Maintenance) that may include report creation , disseminating reports and/or leading the implementation, maintenance, testing and/or functional design of system changes.

Requirements

• Experience working with technology, systems and IS departments
• Advance Microsoft Excel skilled
• Knowledge of ICD-10 and CPT-4 coding and medical terminology
• Proficient in Windows, Word, and Business Analytical tools
• Must have strong analytical and problem-solving skills.
• Strong communication skills, including an ability to communicate with staff at various levels, including both front line staff and senior management.
• Must have excellent analytical, organizational, and interpersonal skills, as well as a strong background in pharmacy claims processing, and the managed care industry
• Experience working within the Payer / PBM market (in particular Medicare and Medicaid, Part D and its components) with understanding of benefit plan structures, NCPDP standards, HIPAA regulations, and other pharmacy products and services
• Must understand the work flow of pharmacy claim processing or related Med D functions. For example, Enrollment, Drug Utilization
• Review, Adjudication, Pricing, Payments/Billing, EOB, PDE, FIR, Reprocessing, or other features resident in or working in cooperation with a pharmacy benefit system
• Strong business knowledge of Pharmacy Benefit Systems and Drug benefit plan administration with exposure to COTS / custom applications would be an advantage
• Ability to effectively present information and respond to questions from clients, management and technical associates
• Collaborate across the entire product team to ensure product dependencies, goals and experiences are defined and met
• Document business requirements and user journeys
• Must have agile project execution experience along with familiarity to scrum tools and methodologies
• Should have excellent verbal, written, documentation and presentation skills

Note: U.S. citizens and those authorized to work in the U.S. are encouraged to apply. We are unable to sponsor at this time.