Payment Cycle Analyst III

• Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members
• Research and provide recommendations to the Reimbursement Committee for reimbursement of services
• Research claim results to determine potential errors/discrepancies attributed to clinical edits, claims coding, payment policies, and application of fee schedule and rates
• Develop business requirements for payment decisions and manage the implementation process with Configuration, CES, IT and Market stakeholders
• Lead special projects to ensure payment discrepancies are resolved and communicated to the appropriate parties
• Provide payment expertise at provider meetings, Medicaid Fairs, market workgroups, and any other industry related events
• Review and interpret regulatory items and policy manuals to ensure test scenarios support the requirements
• Identify test result outputs and Claim SOPs that need to be modified or created to support new or changed business requirements
• Build library of re-usable tests plans & scripts to support the Market
• Document the status of test results and gaps in testing for future improvements
• Validate Impact Reports to ensure the criteria is consistent with story and universe of claims impacted by the changes
• Approve UAT test scripts and test results prior to promoting changes to production and monitor post production results
• Validate MCA Tests for expected results and communicate information to Reimbursement Analysts and HP Managers for provider notification
• Conduct both systemic and targeted analysis to identify issues with testing and identify process changes for improvement
• Create effective written and oral communication materials that summarize findings and support fact based recommendations that can be shared with Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups
• Perform any other job related duties as requested.

• Bachelor's degree required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of health plan experience is or equivalent experience with health plan operations and configuration required
• Experience with user testing required
• Experience with payment methodologies and industry pricers (ex: DRG, APC, SNF, RBRVS) preferred

• Advanced proficiency level experience in Microsoft Suite to include Word, Excel, PowerPoint, Access and Visio
• Strong computer skills and abilities in Facets or equivalent claim payment system is preferred
• Strong analytical skills with the ability to effectively communicate findings with the Leadership Team
• Demonstrated understanding of claims operations, configuration, and testing related to managed care
• Understanding of regression, unit, and user acceptance testing is required
• Effective listening and critical thinking skills
• Effective problem-solving skills with attention to detail
• Creative thinking to develop positive and negative test scenarios
• Excellent written and verbal communication skills
• Ability to work independently and within a team environment
• Strong interpersonal skills and high level of professionalism
• Ability to develop, prioritize and accomplish goals
• Understanding of the healthcare field and knowledge of Medicaid, Medicare, and Marketplace
• Strong working knowledge of claims processing edits and logic
• Familiar with CMS guidelines / HIPPA and Affordable Care Act

• None required

• General office environment; may be required to sit or stand for extended periods of time
• Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business