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The Business Analyst is responsible for reporting, process improvements, and quality assurance to support the Medicaid or Medicare Integrity contract operations. This position is also responsible for ensuring assigned deliverables meet HMS Federal and client quality standards for accuracy, timeliness, and cost. Responsible for performing quality assurance checks, working with stakeholders to articulate quality standards for deliverables, training and coaching stakeholders on meeting quality standards, and contributing to the on-going identification of improved methods and processes for achieving quality. Main Duties and Responsibilities: - Conducts research and ongoing monitoring of relevant State specific billing/reimbursement regulations. - Conducts claims research using the appropriate systems. - Provides support to internal staff, subcontractors and providers with respect to Medicaid related issues. - Identifies training needs through review of team and individual quality scores. - Creates formal training classes to ensure compliance with customer requirements and Generally Accepted Governmental Auditing Standards. - Conducts internal and external training to increase audit efficiency and audit quality. - Collaborates with the Audit and Medical Review Services Management team to develop and revise policies, procedures, and work instructions. - Reviews quality data & identifies trends/patterns recommending appropriate action in a timely and proactive manner. - Participates and leads the departmental and team ISO activities/audits as needed. - Participates in and contributes to the quality management system. - Writes reports to meets project timelines and deliverables. - Partners with peers to develop a cohesive audit deliverable to ensure high quality. - The role also requires an individual with strong leadership capabilities, initiative, problem solving skills and extensive experience with providing reports and analysis to senior level management. - Provide root-cause analysis and expertise when compiling and reporting operational results and contract deliverables. - Proactively identify and develop solutions to resolve critical issues. - Influence and promote change in order to improve performance results, organizational effectiveness and systems/quality/services. - Assists in the development and maintenance of processes that measure efficiency, productivity, and monitor customer satisfaction. - As an essential function, this position is responsible for complying with the company's Corporate Compliance Program as it applies to the individual job duties, the department, and the company. - This position will exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates, and/or agents. - Any other duties as assigned
Required Function 2:
Required Skills: - Strong analytical and reporting skills with an aptitude for not only delving into the details, but also stepping back to see the big picture to identify issues. - Knowledge of Medicaid Regulations, Claims Processing, and Reimbursement Methodologies preferred. - Microsoft Office skills including Excel, Power Point, and Word required. - Independent thinker, logical, strategic, with a high focus on problem resolution and attention to detail. - Outstanding verbal and business writing communication skills as well as strong presentation skills. - Proven team and project leadership abilities. - Ability to work independently and within cross- functional teams required - Demonstrated ability to meet and exceed project deadlines while producing high quality products. - Technical writing skills and ability to produce work free from typographical or spelling errors. - Pro-active and results focused attitude. - Willingness and ability to work additional hours to ensure reporting deadlines are met. - Ability to maintain high quality work while meeting strict deadlines. - Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements. - Primarily sedentary work with occasional standing, walking, lifting, moving, and traveling to other departments or work sites. - Ability to work in normal office environment. - Ability to sit and work at a computer for an extended period of time. - Ability to travel up to 15% is required. Required Education/ Experience: - Bachelor's degree in nursing, social or health service, or business related field preferred. - 3+ years of experience in performing medical record documentation review or utilization review and providing technical training on coding and medical review components. - Experience related to Federal Government, State Government or Managed Care Healthcare contracts required. - Proven track record monitoring results and tackling problems directly and with urgency. - Demonstrated leadership and management competencies and skills including operational excellence, exceptional communication and customer service skills.
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