Payment Cycle Analyst II

🕒 September 22

🇺🇸 United States – Remote

💵 $62.7k - $100.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Define clinical and payment policy requirements for configuration of clinical editing systems • Research potential reimbursement policy claim edits, including support sourcing, data analysis, regulatory consistency, and network impact • Research claim results to identify errors and discrepancies related to clinical edits, coding, payment policies, fee schedules, and rates • Conduct systemic and targeted analysis to identify reimbursement errors and root causes • Prepare, review, and obtain approval for clinical and payment policy analysis and documentation before implementation • Provide input to UAT and conduct post-production validation • Create written and oral communications summarizing findings and fact-based recommendations for providers, provider associations, and Health Partner Managers • Document open issues, configuration design, and final resolutions • Review and interpret regulatory items and deliver required updates • Support system change policy initiatives, provide updates in payment policy meetings, and present to stakeholders • Monitor configuration and claims SOPs for payment accuracy • Assist in developing policies and procedures for claims processing, COB, appeals, and adjustments • Ensure payment policies and decisions are documented and support provider education activities with the Health Partner team • Perform other duties as requested

🎯 Requirements

• Bachelor’s degree or equivalent years of relevant work experience is required • Minimum of three (3) years of health plan experience is required or equivalent experience with provider coding and claim payment policies • Experience working with clinical editing software is preferred • Advanced proficiency in Microsoft Suite, including Word, Excel, Access, and Visio • Strong computer skills and abilities in Facets • Understanding of claims operations, configuration, and clinical editing related to managed care • Strong working knowledge of ICD-9/ICD-10, CPT, HCPC, REV, DRG, and RUG code sets • Knowledge of HIPAA Transaction Codes • Data analysis and trending skills • Strong written and verbal communication skills • Strong claims processing edits and logic knowledge • Familiarity with CMS guidelines, HIPAA, and the Affordable Care Act • Familiarity with reporting packages and running system reports • Certified Medical Coder preferred • Ability to work independently and within a team environment • Occasional travel of up to 10% may be required

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Occasional travel to meetings, training, and conferences