Claims Analyst - AlohaCare

Apply on line at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication, and a generous benefits package.

Aloha Care’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect, and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. Aloha Care’s comprehensive benefits package includes low-cost medical/vision, dental, and drug insurance, Paid Time Off (PTO) Plan, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected in the communities we serve.

The Opportunity:

The Claims Analyst will be responsible for leading special project activities to improve the efficiency/reduce cost of processing claims. These activities could include developing new processes or recruitment activities with providers to improve the claims end-to-end experience.

Primary Duties and Responsibilities:

Analysis:

• Perform data analysis/trending to identity areas for process improvement by leveraging process automation and/or targeted provider billing guidance.
• Review pended claim reports to identify and create new workflows for process automation and analyze areas of improvements.
• Review system setup, create business configuration guidelines to reduce claims processing costs and monitor progress.
• Develop and maintain requirements/business rules for claims enhancements to comply with Federal and State requirements.

Documentation and Training:

• Create business process models for new and established processes.
• Create and maintain departmental process documents and training materials.
• Create and maintain provider billing guidance.
• Create requirement documentation for configuration and enhanced editing vendors.

Other Duties and Responsibilities:

• Create cross functional workflows and procedures.
• Assist with implementation of Claims related projects.
• Provide support and training for the Claims team.
• Reviews Medicare, State and Federal Correspondence to advise Claims management staff of requirement changes that could impact business processes.
• Conducts system/upgrade testing as needed.
• Maintains relationships with clearinghouses and payment vendors for support of electronic data transmission processes.
• Support Encounter Analyst with various activities to increase acceptance rates.
• Conduct process improvement activities for established workflows.
• Assist other claims team members with processing questions and training.
• Fosters collaborative relationships with internal customers.
• Communicate with external parties for resolution of Claims related issues.
• Reviews claims reporting data to identify trends, track Claims KPIs and analyze areas for growth.
• Supports internal Claims audit processes.
• Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules, and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• High school diploma or equivalent
• Minimum of five (5) years of claims processing experience and or equivalent combination of education, experience, and credentialing.
• Excellent verbal and written communication skills required.
• Excellent attendance, punctual and reliable.
• Experience in operation of general office equipment to include PC, fax/copy machine and ACD Mitel Phones.
• Previous healthcare benefit/reimbursement experience in Medicaid, Medicare, or Commercial programs.
• Experience with provider billing or medical records systems.
• Experience with provider engagement training and problem resolution
• Ability to engage with other teams in a positive manner and develop new workflows as needed.
• Highly proficient skills using Microsoft Programs; Word, Excel, and Outlook and data analytic tools.
• Must have ability to analyze data sets and trends for anomalies, outliers, trend changes and opportunities by using data analysis skills and reporting tools.
• Must have the ability to read, analyze, and interpret business documents such as Claims workflows, Medical Policies, Medicare, and Medicaid Guidelines.
• Ability to perform advanced claims research, problem identification and claims resolution.
• Possess an in-depth knowledge of CPT, ICD-(/ICD-10, HCPCS, UB04 form, and CMS-1500 forms as they relate to insurance payment to meet Health care insurance and medical coding, billing, and payment guidelines

Preferred Requirements

• Bachelor’s Degree: Business Administration, Accounting, or related field
• Previous experience with Medical Claims Processing or Billing
• Previous experience with QNXT
• Previous experience with Medicaid or Medicare program.
• Previous experience with Business Process Modeling or Training
• Health care industry experience within managed care, hospital, medical office or equivalent.
• Collections or payment recoveries experience

Mental, Physical and Environmental Demands:

• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Inside working conditions
• No environmental hazards
• Requires operation of general office equipment to include PC.

Salary Range: $24.00 - $30.00 an hour

AlohaCare is committed to providing equal employment opportunities to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans’ status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.