Claims Implementation Analyst

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Claims Implementation Analyst is responsible for assisting in analyzing, documenting and coordinating the implementation of claims business requirements. The Claims Implementation Analyst will represent claims operations in projects, system upgrades and identifying opportunities for automation. The Claims Implementation Analyst will support business decision making by querying and analyzing data, identifying root causes, and providing data driven recommendations. This is a fast-paced and rapidly growing environment.

Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits

Key Functions/Responsibilities:

· Responsible for the overall success of implementations including applicable testing and results verification before sign-off and Production.

· Assist in the on-going audit of configurations for new and existing claims business rules within the claims processing system.

· Identify claims configuration and contract implementation defects and improve departmental performance by supporting quality, operation efficiency and production goals.

· Query claim data to determine root cause, trend, summarize findings and offer recommendations.

· Work departmentally and interdepartmentally to recommend and implement modifications to existing claims operations functions.

· Ensure post implementation accuracy of Claims Operations upgrades and implementations.

· Collaborate with project teams to develop project plans, establish deadlines, monitor milestone completion, provide timely reporting of issue that impact progress, and resolve conflicts.

· Prepare routine reports as needed (financial, quality, production, operational efficiency, etc.).

· Assess and prepare to address the operational impacts, workflow, and training issues of the assigned project(s).

Identify automation opportunities.

Write clear and well-structured business requirements and documentation

Complete other projects and duties as assigned.

Supervision Exercised:

· No direct reports; manages projects in a matrixed environment

Supervision Received:

· Weekly supervision with Manager of Claims Business Engineering

Qualifications:

Education Required:

High School Diploma

Associates Degree or the equivalent combination of training and experience, and/or 3 - 5 years related experience.

Education Preferred:

· Bachelor's Degree from an accredited institution.

Experience Required:

· Experience performing claim or data analysis in a managed care, commercial health plan or other healthcare related environment

· Experience utilizing analytical tools such as SQL, Tableau, and Cognos

· Experience in Microsoft Excel creating and utilizing formulas, pivot tables, VLOOKUPs and macros.

· Experience analyzing data, data mining, managing projects and identifying trends.

· Experience gathering and communicating business requirements in a simple and easy to understand manner to other staff.

· Experience creating presentations in Microsoft PowerPoint.

Experience Preferred/Desirable:

· 5 + years claims experience; Facets experience preferred.

· Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

· Analyze current and potential systems and serve as a resource and subject matter expert (SME) on all aspects of project plan development to support business strategies. Ability to create effective job aides and review them with key stakeholders at multiple levels of the department and organization.

· Knowledge of Medicare and Medicaid programs.

Required Licensure, Certification or Conditions of Employment:

· Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

Proficient in processing claims from multiple lines of business and claim types.

Analytical skills and using mental reasoning or research to gain insight into or solve problems.

Experience or skill with finding and analyzing patterns in data.

Advanced technical skills.

Ability and willingness to handle increasing workload and responsibility.

Ability to communicate clearly in written and verbal form.

Effective collaborative and proven process improvement skills.

Strong oral and written communication skills; ability to interact within all levels of the organization.

A strong working knowledge of Microsoft Office products andTableau Reporting.

Demonstrated ability to successfully plan, organize and manage projects

Detail oriented, excellent proof reading and editing skills.

Ability to solve problems under time pressure, with frequent interruptions. Capability of multi-tasking including strong organizational and time management skills.

Ability to analyze, compile, format, and present data to a variety of stakeholders.

Strong critical thinking, analytical, and problem-solving skills

Working Conditions and Physical Effort:

Ability to work OT during peak periods. (Non-Exempt Positions)

Regular and reliable attendance is an essential function of the position.

Work is normally performed in a remote work environment.

No or very limited physical effort require

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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Important info on employment offer scams:

According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not reach out to individuals via text, we do not ask or require downloads of any applications, or “apps”, and applicant screenings, interviews and job offers are not conducted over text messages or social media platforms. We do not ask individuals to purchase equipment for, or prior to employment. To avoid becoming a victim of an employment offer scam, please followthese tips from the FTC (https://consumer.ftc.gov/consumer-alerts/2023/01/looking-job-scammers-might-be-looking-you?utm_source=govdelivery) .