Senior Claims Optum/Pricing Analyst
Advantasure

Chicago, Illinois

Posted in IT


This job has expired.

Job Info


SUMMARY:

The Optum Claims Pricing Specialist is responsible for ensuring that CMS rules, CMS fee schedules, pricing changes are updated to accurately result in proper pricing and editing of claims for multiple clients. This includes testing of CES billing edits as a result of CMS updates, and Optum pricing edits, affecting claims adjudication.

RESPONSIBILITIES/TASKS:

  • Serve as primary claims point of contact for inquiries related to fee schedule and pricing updates in the Optum HSS Product.
  • Serve as primary claims point of contact for inquiries related to CES edits and updates
  • Monitor and test changes/updates within the CES configuration by developing testing scenarios, procedures and controls as well as provide recommendations for ongoing improvement
  • Partners with the claims configuration team on testing and system adjudication logic
  • Performs UAT of pricing and edit updates to ensure that claims are pricing/editing appropriately
  • Perform quantifications to identify claims affected by retroactive fee schedule, pricing, and edit updates
  • Responsible for timely and accurate quantification of claims affected by retroactive pricing and edit changes and reprocessing of affected claims after edit and pricing updates.
  • Participate in meetings related to CMS transmittals and MAC bulletin updates
  • Analyze and interpret CMS changes and other intelligence information for potential impacts to the CES software and claims adjudication
  • Configure benefit tables and payment/fee schedules in the claims adjudication system
  • Develop and improve workflows and business processes to decrease operational costs, and improve overall quality and update policies and desk level procedures (DLPs) accordingly
  • Create, load, maintain or audit fee schedules as assigned
  • Participate in research of claims pricing/edit disputes
  • Identify trends in errors and recommends improved processes and/or training needs
  • Duties and responsibilities are not intended to be all-inclusive; they represent key elements considered necessary to successfully perform the role.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EDUCATION OR EQUIVALENT EXPERIENCE:

Bachelor's degree in related field required, or equivalent experience in Healthcare claims adjudication logic, database maintenance and project management. Must have knowledge of CPT, ICD-9/ICD-10, HCPCS, Revenue Codes and pricing methodologies.

EXPERIENCE:

Minimum of 5-7 years' experience in the Healthcare industry. Demonstrated technical knowledge of operations (example: claims processing, enrollment, provider file maintenance) with ability to interpret and document business requirements. Analyst experience with proven experience in operational analysis, data analysis, and problem resolution type activities is required.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
  • Demonstrated ability to process professional and institutional health care claims and understanding of claims adjudication logic
  • Understanding of core processing systems in relation to configuration set-up and ability to resolve issues
  • Demonstrated understanding and experience working with government agencies such as CMS, Medicaid, etc. along with interpreting agency and contract requirements
  • Experience in the mapping of benefits, loading and maintenance of healthcare benefits
  • Understands how provider data works as part of the claim adjudication process
  • Ability to plan, organize, direct, and control projects.
  • demonstrates strong analytical skills and display an "own it" cultural belief daily.
  • Excellent written and verbal communication skills.
  • Excellent analytical, organizational, and problem-solving skills.
  • Ability to lead and contribute to process improvement projects.
  • Ability to work successfully as both a team player and an individual contributor with little supervision.
  • Ability to manage multiple clients/priorities.
  • Significant creativity to utilize system capabilities to meet benefit design.
  • Ability to develop, implement, and monitor policies and procedures.
  • Proficient in current industry standard PC applications and systems (e.g., Access, Excel, and Word).

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.


This job has expired.

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