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 and security of data while optimizing processes for EviCore Claims processing.

• Document and develop application functionalities and data configurations.

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

• Guide the Senior Analyst on complex enhancement and configuration designs.

• Offer Claims Systems subject matter expertise to various internal departments, including Claims Configuration, Client Engagement, Program Leads, Claims IT Development, and QA.

• Lead calls with external clients and provide support regarding all aspects of the Claims System application.

• Define business, technical, and claims data exchange requirements.

• Provide instruction on mapping data files for providers, members, authorizations, claims, and associated data.

• Create test/use cases, conduct System Integration testing, and support User Acceptance testing for client implementations and internal integration/migration efforts.

• Develop simple to complex SQL queries to analyze Claims System configurations and claims data.

• Update configurations via Access Database.

• Perform post-production claims reviews to validate changes made in production.

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

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

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

• Execute tasks with self-direction and make necessary decisions.

⛳️ Requirements

• Bachelor's degree in a computer-related field preferred or equivalent work experience.

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

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

• Proficient in executing complex queries using Microsoft SQL.

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

• Skilled in Microsoft Excel, encompassing pivot tables, charts, and formulas.

• Strong technical capabilities, demonstrated critical thinking, and exceptional communication skills.

• Well-versed in the claims lifecycle and claims adjudication framework.

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

• Familiarity with database management systems such as DB2 and SQL Server.

• Experience in external client-facing roles preferred.

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

• Ability to secure home internet through cable broadband or fiber optic service with a minimum of 10Mbps download/5Mbps upload.

🏝️ Benefits

• Remote work arrangement.

• Internet connection through a cable broadband or fiber optic internet service provider with minimum speeds of 10Mbps download/5Mbps upload while working from home.

• Equal employment opportunity protections.

• Reasonable accommodation support for the online application process.

• Eligibility for tobacco/nicotine cessation programs in applicable states.