Claims Systems Lead Analyst

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Oversee intricate Claims Systems projects and implementations within the claims adjudication engine.

• Ensure the integrity, security, and optimization of data for EviCore Claims processing.

• Document and enhance application functionality and data configurations.

• Utilize Azure DevOps with project methodologies to manage and maintain tickets for Claims System projects and requests.

• Guide Senior Analysts on sophisticated enhancement and configuration designs.

• Provide subject matter expertise on Claims Systems to Claims Configuration, Client Engagement, Program Leads, Claims IT Development, and other internal teams.

• Lead external client meetings addressing all elements of the Claims System application.

• Establish business, technical, and claim data exchange requirements.

• Instruct on data file mapping for providers, members, authorizations, claims, and related data.

• Develop test/use cases, conduct system integration testing, and support user acceptance testing for client implementations and internal integration/migration efforts.

• Construct simple to complex SQL queries to analyze Claims System configuration and claims data.

• Update configurations using Access Database.

• Perform post-production claims reviews to confirm the accuracy of deployed changes.

• Investigate claim processing issues and conduct root cause analysis for Claims Configuration.

• Collaborate and communicate with internal and external business operations, IT, and QA departments.

• Assist in reporting development, RFP data processing requests, training, maintenance transition, and process/product workflow documentation.

• Carry out duties independently and make necessary decisions.

⛳️ Requirements

• Bachelor’s Degree in a computer-related field preferred or equivalent work experience.

• Minimum of 5 years of experience in claims and healthcare required.

• 5+ years of experience in medical Claims Systems Configuration preferred.

• Proficient in running complex queries using Microsoft SQL.

• Required proficiency in Microsoft Access Database, including queries and data manipulation.

• Required proficiency in Microsoft Excel, including pivot tables, charts, and formulas.

• Strong technical aptitude, proven critical thinking abilities, and exceptional communication skills required.

• Extensive knowledge of claims lifecycle and claims adjudication framework.

• Familiarity with industry-standard claims data types and editing rules, including ICD, CPT/HCPC, Rev Codes, and NCCI.

• Experience with database management systems, including DB2 and SQL Server.

• Preferred experience in client-facing roles.

• Experience in creating test plans/use cases and SDLC models.

• For remote work, internet connection must be via cable broadband or fiber optic service with a minimum of 10Mbps download and 5Mbps upload.

🏝️ Benefits

• Option for remote work (either occasionally or permanently), contingent upon cable broadband or fiber optic internet with a minimum of 10Mbps download and 5Mbps upload.

• Tobacco-free policy; a qualifying smoking cessation program may be available where legally permissible.

• Commitment to equal employment opportunity.

• Reasonable accommodations for the online application process.