Job Description
About Us: Join a global organization dedicated to improving health outcomes through advanced technology and care. Our mission is to connect people with the resources they need to live healthier lives. We are committed to a culture of diversity and inclusion, offering talented peers, comprehensive benefits, and career development opportunities.
Role Overview: As a Senior Business Analyst Consultant in Payment Integrity, you will play a crucial role in enhancing health care delivery by identifying and implementing payment integrity opportunities. You'll collaborate with various stakeholders, including Market, Finance, Product teams, Medical Directors, and Healthcare Economics, to drive improvements and ensure operational excellence.
Key Responsibilities:
Payment Integrity Strategy: Develop and deploy a Payment Integrity (PI) operating model, including building operational dashboard reporting, identifying program gaps, and creating an implementation roadmap.
Business Case Development: Create compelling business cases to influence market partners and stakeholders, prioritizing and deploying new edits, vendors, and programs.
Standardized Reporting: Produce and manage standardized savings reports using approved methodologies across multiple domains.
Vendor Management: Hold PI vendors accountable for performance and implementation timelines.
Market Support: Become proficient in California's regulatory, compliance, network contracting, and claims processing areas to effectively deploy payment integrity programs.
Program Management: Lead program management for all CA payment integrity services, including Claims Editing, Claims Cost Management, Audit and Recovery Operations, Premium Audit Services, and Fraud and Abuse.
Reporting and Compliance: Ensure consistent, standardized reporting and adherence to state and federal compliance policies, reimbursement policies, and contract compliance.
Qualifications:
Experience: 5+ years in the healthcare industry, with expertise in MA, Medicaid, and/or commercial lines of business.
Implementation Skills: Proven experience with product/vendor implementations and various claims payment methodologies.
Technical Proficiency: Skilled in Microsoft Office (Word, Excel, PowerPoint, Visio) with strong data analysis and presentation abilities.
Analytical Abilities: Demonstrated capability to gather and analyze information, forming comprehensive recommendations and solutions.
Consulting Skills: Solid consulting and influencing skills, with the ability to identify root causes and drive solutions.
Interpersonal Skills: High degree of interpersonal skills and relationship building to engage clients effectively.
Prioritization: Proven ability to manage competing priorities and execute effectively in a fast-paced environment.
Preferred Qualifications:
Certifications such as CPC, CPCO, AHFI, HCAFA, or CFE.
Experience interpreting provider contractual agreements and managing a comprehensive portfolio of programs.
Knowledge of California health plan operations and financial analysis/audit experience.
Compensation and Benefits:
Additional Benefits: Comprehensive benefits package, incentive programs, equity stock purchase, 401k contribution, and more (subject to eligibility).
Application Process: This position will remain open for a minimum of 2 business days or until a sufficient candidate pool is reached. The job posting may be removed early based on applicant volume.
Commitment to Diversity: We are an Equal Employment Opportunity/Affirmative Action employer. We welcome applicants from all backgrounds and ensure that everyone has the opportunity to succeed.
Join us and make a meaningful impact in advancing health equity on a global scale!
Employment Type: Full-Time
Salary: $ 160,000.00 Per Year
Job Tags
Full time, Contract work, Remote job,