This site uses cookies. To find out more, see our Cookies Policy

Lead Analyst COB C/D Recovery in Southfield, MI at AF Group

Date Posted: 11/30/2018

Job Snapshot

Job Description

COBX Senior Health Services
SBD Business Performance and Finance
Major Michigan health insurer located in southeast Michigan seeking experienced Lead Analyst for Medicare business.
 SUMMARY

Applies analytical and leadership skills to manage workflow, track, and report operational performance for COB Part C/D and Recovery activities. Lead the implementation of new processes and enhancements to improve performance and quality. Execute control validation oversight and analyze data to ensure quality and CMS requirements are met. Utilize strong CMS Medicare Advantage, Prescription Drug, and MSP (Medicare Secondary Payer) knowledge to train, coach, and provide feedback on team performance.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

  1. Establish and manage workflow. Monitor, track, and report Part C/D COB and Recovery activities. Ensure timeliness is met and expected outcomes achieved.
  2. Lead the implementation of new processes and policy requirements.
  3. Lead the identification of process improvement opportunities. Identify barriers and lead the development of solutions.
  4. Support control validation oversight and analyze data to ensure quality and maintain compliance with CMS requirements and BCBSM MA policies.
  5. Support vendor oversight and operations for contracted services.
  6. Train, coach, and mentor team members. Provide feedback on team performance.
  7. Perform data reconciliation.
  8. Research and resolve complex inquiries.
  9. Execute department functions as needed.
  10. Serve as a subject matter expert regarding CMS and BCBSM MA policies related to COB and Recovery. Represent the department on cross departmental work groups and committees.
  11. Assist leadership in analyzing data and reporting findings.
  12. Perform other related duties as assigned.

ADDITIONAL DEPARTMENT JOB DUTIES

  1. Research and validate identified claim overpayments.
  2. Support audit concept management process.
  3. Support the implementation of claim overpayment recovery and avoidance initiatives

ADDITIONAL DEPARTMENT REQUIREMENTS

  1. Strong working knowledge of claims operations including Medicare billing and reimbursement policy.
  2. Working knowledge of Microsoft Access, other Microsoft office applications, and related software programs.
  3. Research and validate identified claim overpayments.
  4. Support audit concept management process.
  5. Support the implmentation of claim overpayment recovery and avoidance initiatives
ADDITIONAL DEPARTMENT PREFERENCES
  1. Medicare professional and facility claim processing experience and/or auditing highly desired.
  2. Medicare Advantage plan operations experience is preferred.

EDUCATION AND/OR EXPERIENCE

  1. Bachelor's degree in related field required or equivalent experience including Part C/D plan operations.
  2. Four (4) to seven (7) years experience in related field.
  3. Knowledge of CMS compliance guidelines and Part C/D COB plan requirements, COB Rules of Primacy, Medicare Secondary Payer (MSP) regulations. Experience establishing MSP coordination periods.
  4. Strong organizational, problem solving, verbal and written communication skills.
  5. Strong analytical and reporting skills.
  6. Ability to work independently, within a team environment and with multiple priorities.
  7. Proficient in current industry standard PC applications and systems (e.g., Access, Excel and Word).
  8. Ability to train and coach.
  9. Ability to lead the implementation of new processes, workflows, and enhance existing operations.
  10. Ability to work closely with the technical support team in understanding and resolving systems issues.
  11. Ability to develop, implement, and monitor policies and procedures.
  12. Familiarity with check posting and payment tracking.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER SKILLS AND ABILITIES

  1. Ability to reconcile data.
  2. Knowledge of and/or ability to research, interpret and apply Medicare and BCBSM MA Part C/D COB policies.
  3. Knowledge of BCBSM MA claims, enrollment, finance, imaging and other relevant systems.
  4. Other related skills and/or abilities may be required to perform this job.

OTHER REQUIREMENTS

LANGUAGE SKILLS

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS

Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

REASONING ABILITY

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, and ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to outside weather conditions. The noise level in the work environment is usually very quiet.

ADDITIONAL INFORMATION

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.