SCOPE OF ROLE

The Senior Claims Analyst has oversight for claims processing, verifying information on submitted claims, reviewing the policy to determine which charges are eligible for reimbursement, and auditing any vendor-processed claims. They ensure all business rules set by Bright Health Plan are followed by vendors and that payments are made according to CMS guidelines, Bright Contract, and plan benefit designs. The Senior Claims Analyst participates in audits, coordinating with Compliance and Legal to ensure Bright Health Plan provides all the requested data, navigates systems as needed during the audit, and provides any follow-up requested by auditors.

ROLE RESPONSIBILITIES

The Senior Claim Analyst job description is intended to point out major responsibilities within the role, but it is not limited to these items.

RESPONSIBILITIES

• Partner with Configuration Provider Data, Network, and vendors to ensure claims are paid to providers and members accurately.
• Monitor policies and procedures for Bright Health with claims.
• Monitor daily reporting distributed by internal staff and vendors (claim reports, document aged reports)
• Provide recommendations on the design of the claim payment system configuration.
• Act as a liaison between Operations, Finance, Compliance, and the provider network serving as claim SME.
• Serve all stakeholders through continuous monitoring and auditing of claim processing, educational and problem-solving support
• Maintain daily contact with operations management, clinical leadership, and appropriate company leaders
• Handle adverse and politically difficult situations, as payment accuracy has a significant impact on the financial performance of the organization and our providers, processes related to claims processing, and managed care negotiations along with directly impacting the financial performance of Bright Health Plan
• Read, interpret, and formulate complex computer system rules and managed care reimbursement payment methodologies including but not limited to CMS payment rules and requirements.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree in Business Administration or related field required.
• Ten (10) or more years of experience in Enrollment, Premium Billing, Claims, Member and Provider Service, and Appeals at a health insurance company will be considered instead of a degree.
• Five (5) years of experience in the application of CMS billing guidelines required.
• Five (5) or more years of health care systems and inter/intra-relationships specific to value-based contracting activities required.
• Five (5) or more years of complex managed care concepts/processes, and health insurance pricing and associated benefit design knowledge required.
• Intermediate or advanced Excel skills for data analysis required.

PROFESSIONAL COMPETENCIES

• Able to create and maintain strong working relationships.
• Complex problem-solving skills.
• Able to manage resources in a matrix environment, communicating and influencing effectively at all levels of the organization.
• Effective at relationship management.
• Broad knowledge of health insurance and services delivery and functions.
• In-depth knowledge of federal, state, and CMS-based requirements and the ability to develop, distribute and administer Medicare programs in a compliant manner.
• Success managing multiple initiatives and priorities simultaneously.
• Able to quantify the impact and ROI of initiatives.
• Experience in government programs including Exchanges, Medicare, and/or Medicaid.
• Experience with integrating health plan support services and other elements of operations in high-growth environments.
• Certified commercial medical billing coder a plus

LICENSURES AND CERTIFICATIONS

• No licensures and/or certifications are required for this role.

WORK ENVIRONMENT

• This position is remote from anywhere, but will be required to work 8 am to 5 pm in the Pacific Time Zone.
• Travel may be required.