Business Process Specialist - Integrated Resources, Inc

Bellaire, TX 77401

Job Title: Business Process Specialist
Location : Houston, TX (Hybrid)
Duration: 3 Months Contract

Duties:

To support and develop programs aligned with Health Plan strategic goals through effective and timely assessment and equitable distribution of resources and assignments, education and implementation of processes and procedures that provide and maintain a cost-effective provider network for Texas Children's Health Plan.
Through participation in Medical Policy, Reimbursement Committee, and other workgroups as needed, provides support for the facilitation of process and/or system changes.
Proposes, implements, and supports quality control measures related to practice and/or system changes that impact claims adjudication.
Performs review of current and newly implemented processes to ensure accurate reports and/or other deliverables.
Leads collaborations with other departments to ensure compliance standards are met.
Process and workflow management for audit response, contract adherence, and regulatory compliance functions.
Prioritizes key project tasks and deliverables and identifies project risks, issues and dependencies.
Must demonstrate ability to achieve effective issue resolution.
Must have excellent written and verbal communication skills, and the ability to interact with a wide variety of individuals
and handle several complex situations simultaneously.
Must have leadership, creativity, integrity and initiative, and sound problem-solving skills.
Must provide attention to detail and follow up.

Department needs a certified medical coder that is able to do data analysis

Functions include skill sets tied to claims, Payment Integrity, Coding, and Business Process Analyst functions
Collaborate system and data configuration with partners, perform user acceptance testing, and analyze postproduction reports for issues
Develop enhanced, customized prospective medical coding and reimbursement policies and necessary coding configuration requirements
Use and maintain reimbursement policy library and be a SME on coding guidelines and impact to provider reimbursement.
Analyze, measure, manage, and report outcome results on system configuration / edits implemented.
Knowledge and experience of claim operations, health care reimbursement, public health care programs and reimbursement methodologies (Medicaid and Medicare)
Collaborate system and data configuration with partners, perform user acceptance testing, and analyze post production reports for issues
Experience with Texas Medicaid
Experience in Tapestry (Preference)

Skills:

Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating/analyzing claim outcome results for accurate industry standard coding logic and policies (i.e.. Center for Medicare & Medicaid Services (CMS) & MA Medicaid, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs) both practitioner and facility, modifier to procedure validation, and other CMS and American Medical Association (AMA) guidelines, etc.)
Certified Professional Coder (CPC)
Certified Inpatient Coder (CIC)
Certified Professional Medical Auditor (CPMA)
Experience with Texas Medicaid
Experience in Tapestry (Preference)

Education:

Required- Bachelor's Degree- Business, Health Care Administration, Public Health, Nursing, MIS or an IS related field.
Required- 2 years’ Experience in a managed care organization (MCO) or related healthcare organization.
A master’s degree in business, Health Care Administration, Public Health, Nursing, MIS or an IS-related field may substitute for 2 years of required experience.

Source : Integrated Resources, Inc