Healthfirst Operations Analyst Claims in New York, New York

Overview:

Healthfirst is a provider-sponsored health insurance company that serves more than 1.2 million members in downstate New York. With more than 4,000 employees, a network of nearly 30,000 providers, and revenues in excess of $8.6 billion, Healthfirst is one of the largest health plans in the New York City area.

Our members are our North Star, and our mission is guided by their needs and preferences in ensuring a superior experience and access to the highest quality healthcare when and where they need it. Healthfirst’s commitment to quality and member satisfaction has helped us earn top ratings for HMO health plans in New York City.

We know that employees shape our company and connect us to our communities, and we look to recruit and retain intelligent, driven leaders who are passionate about healthcare and embody our five culture drivers: - Dream Big, Plan Wisely - Break Down the Walls - Think Critically, Speak Up, Deliver with Pride - Inspire Through Trust, Lead By Example - Be Unstoppable

Position Summary :

The Claims Operations Analyst is responsible for the tracking and reporting of data and preliminary analysis as it relates to activities which ensure operational effectiveness. Incumbents will assist management by preparing and verifying reports and interpreting trends. The Claims Operations Analyst owns the accuracy and timeliness of reported data as well as communication and resolution of identified issues involving reports and trends.

Healthfirst is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity or expression, veterans, disability status or any other characteristic protected by law.

Responsibilities:

Duties and Responsibilities :

  • Write basic and complex data queries using SAS Enterprise Guide to generate required data sets.

  • Review and verify data sets as necessary.

  • Create, maintain and execute routine queries.

  • Prepare specific and ad-hoc management and operational reports.

  • Review and comprehend functional specifications and requirements for testing.

  • Create and execute tests scripts/cases to meet requirements of functional specifications and ensure proper system functionality and quality outcomes

  • Effectively solicit detail and request additional information from other business units as needed.

  • Promptly Report system testing issues from review and resolution and verify system set up and functionality of approved testing.

  • Produce required input to IS to coordinate testing and production runs of reprocessing process.

  • Create files and submit run requests timely in accordance to SLA requirements and compliance

  • Troubleshoot and resolve issues with the test runs in coordination with other business units.

  • Coordinate finalization of errors with Claims management.

  • Track and trend on claims report statistics on SharePoint logs

  • Report and present preliminary findings based on trending and interpretation.

  • Assist in Claims Audit and processing and data look up as needed.

  • conduct in accordance to regulatory and compliance guidelines and HIPAA

  • Other duties as assigned.

Qualifications:

Minimum Qualifications :

  • High School Diploma or GED from an accredited institution.

  • Familiarity with reimbursement methodologies in terms of claims adjudication, payment and regulation.

  • Experience with one or more of the following: claims adjudication and auditing of claims adjudication; querying/data pulling using data tables and SAS; OR testing by creation and execution of specific scenarios and test cases, identification of issues and resolution through review.

  • Manipulation and creation of Excel spreadsheets; including but not limited to standardizing reports across multiple sheets, utilizing vLookups and functions/formulas, creating, using and interpreting pivot tables, filtering and formatting to generate desired results.

  • Demonstrated ability to work within regulatory and compliance guidelines including accordance to HIPAA

Preferred Qualifications :

  • Bachelor's Degree from an accredited institution.

  • Knowledge of system testing methodologies, test script creation and execution; including Macess or other data management systems.

  • Experience with Medicare/Medicaid programs and familiarity with reimbursement methodologies in terms of claims adjudication, payment and regulation; claims processing practices in a managed care setting

  • Experience with MS Visio, MS Access, MS PowerPoint, SAS, Microsoft VB, Writing Data Queries, PowerMHS.

  • Demonstrated ability to effectively communicate both verbally and written. Your resume should be the first reflection of your overall communications skills.

Requisition ID 2017-15418

Job Locations US-NY-New York

Department Name Claims Business Analytics

Equal Opp Statement -

Healthfirst is an Equal Opportunity Employer and does not discriminated against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity or expression, veterans, disability status or any other characteristic protected by law.

Reasonable accommodation statement -

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 1-800-401-6000. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.