Application Managed Services - AMS - Business Analyst - Remote

About the Role

Key Responsibilities

• Support Optum medical Claims Editing System (CES) for AMS clients
• Partner with Client Leader to establish and strategize how to achieve savings targets
• Identify, research, develop, and size new prepayment editing opportunities for use in Claims Editing System (CES) edit application for assigned healthcare payers
• Proactively review profiling system rules, using coding, policy, reimbursement, clinical, and claims background to determine which rules can be presented to the payer for new medical cost savings opportunities
• Present new edit concepts to clients during Governance meetings, effectively explaining the rule's intent, support, anticipated exposure, and influencing the client to adopt the rule
• Execute the 'Rule Approval' process
• Generate innovative editing ideas that can be scaled across the organization
• Stay current on client configuration and new CES functionality in order to recommend the most effective rule design
• Conduct root cause analysis, including investigation into Knowledge Base updates, LCD updates, and rule logic defects, to recognize and remediate escalated issues
• Interpret complex reimbursement language, policies, and methodologies
• Define, create and maintain rule requirements
• Acquire and maintain working knowledge of multiple platform specific knowledge, customer customizations, databases, file systems and architecture that support the CES application
• Review quarterly Knowledge Base release to determine custom rule impact and maintenance needs
• Build out non-proprietary and proprietary rule library: proactively share information with internal client teams
• Present and evaluate solutions objectively and facilitate conflict resolution
• Evaluate system changes for downstream system and/or organizational impacts
• Build and maintain working relationships with stakeholders
• Facilitate and/or assist with group meetings via Teams and telephonically, providing agendas and meeting minutes
• Identify new opportunities to improve processes, customer relationships, while increasing our value to our client
• Serve as a mentor to new Business Analysts, and routinely identify, develop, and share best practice experience with peers

Requirements

• 3+ years of Healthcare Industry experience (Healthcare reimbursement, claims adjudication, procedure/diagnosis coding knowledge)
• 3+ years of Medicare/Medicaid policy guideline experience
• 3+ years of experience performing Analysis and interpretation of business needs around client payment policies and translate into Business Requirements
• 3+ years of proven ability to interpret technical requirements and business requirements while coordinating with technical staff to help drive solutions for our customers
• 3+ years of proven ability to translate highly complex detailed clinical/technical solution concepts and articulate to technical and non-technical audiences
• 3+ years of experience interfacing with Clients
• 1+ years of experience interfacing at the Executive level
• Proficient with MS Office Applications

Nice to Have

• Experience with CES, Claims Manager
• Content Manager experience
• Business Analyst software support experience
• Training experience
• Medical Coding experience or certified medical coder (AHIMA or CPC)
• SQL or Oracle query experience

Qualifications

• Formal educational qualifications are not explicitly specified in the description

Benefits & Perks

• Competitive salary range of $71,600 to $140,600 annually based on full-time employment
• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Work from anywhere within the U.S.
• Additional benefits subject to eligibility requirements