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Senior Business Analyst, Claim Adjudication

Navitus Health Solutions LLC
Appleton, WI
  • Posted: over a month ago
  • Full-Time
Job Description

Pharmacy Benefits Reinvented- As the industry’s alternative pharmacy benefit manager (PBM), we’re committed to making prescriptions more affordable for you and your members. Here at Navitus, our team members work in an environment that celebrates creativity, fosters diversity.

The Senior Business Analyst, Claim Adjudication is accountable for claims adjudication accuracy for Med D, Managed Medicaid, and Exchange business. They will lead projects that remediate adjudication inconsistencies and errors and will ensure Corrective Action Plans are addressed. This individual develops an understanding of Government Programs regulations and related CMS and/or specific state. The Senior Business Analyst will develop and execute test scenarios/plans, coordinate the user/system testing and is accountable for quality assurance.

Is this you? Find out more below!

How do I make an impact on my team?

  • Subject Matter Expert for Medicare, Medicaid and/or Exchange claims adjudication requirements, as assigned. Ensures the appropriate controls and oversight reporting and compliance with regulatory requirements on the end-to-end process.
  • Leads the Process Oversight Meetings to ensure process compliance and reliability for all assigned processes
  • Is a self-directed informal leader in ensuring appropriate action is taken through completion for process defects, non-compliance, and/or inefficiencies for assigned processes
  • Develops and maintains clear and concise documentation to support claims payment accuracy efforts, including projects, processes and quality assurance activities
  • Identifies and manage changes to Navitus claim adjudication software. This includes Scope Definition, Business Requirements, User Acceptance Testing, and Implementation
  • Establishes processes that are scalable and efficient. Leads or oversees transition to Technical Operations Analysts for ongoing operational maintenance
  • Identifies key metrics to monitor the compliance and accuracy of the process, establishing oversight methods that are operationally efficient and effective. Provides SME assistance when process metrics indicate possible risk to compliance or accuracy and leads any corrective action required once diagnosed
  • Participates in industry conference calls and workgroups related to administration of the Technical Operations department
  • Responsible for reviewing regulatory guidance and leading project teams across the organization to ensure our claim adjudication software is fully compliant
  • Performs data analysis using SQL or business intelligence software
  • Collaborates with Recoveries Product Manager to verify recoveries projects produce the expected results
  • Ensure post-implementation monitoring processes are in place to validate adjudication-related fixes/enhancements are working as expected
  • Oversee timely regulatory audit activities as assigned and addresses opportunities to improve claim adjudication accuracy

What our team expects from you?

  • Bachelor’s degree in business-related field, or equivalent combination of education and experience
  • 3+ years’ experience writing requirements, developing solutions, implementing process improvements, and conducting testing in a business environment preferred
  • Minimum of two years’ experience with Medicare claims adjudication preferred
  • Participate in, adhere to, and support compliance program objectives
  • The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

  • Hours/Location: Monday - Friday Appleton location or remote
  • Paid Volunteer Hours
  • Educational Assistance Plan and Professional Membership assistance
  • Referral Bonus Program – up to $750!
  • Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Eight paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program

Navitus Health Solutions LLC


Appleton, WI
54913 USA



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