Claims Compliance Analyst

SCOPE OF POSITION:

Participate in monitoring and reviewing relevant policies and regulations.  Work with Claims Department management in developing claims procedures and coordinating the implementation within all areas of Claims Operations.  Assist in developing and maintaining a centralized repository of Claims Operations decision support tools and Claims Administration Procedures (CAPs), generating periodic management reports, and responding to RFP requests.  Also responsible for the integrity and timeliness of the companywide submission of encounter data to support all Federal and State regulatory requirements.

 

ESSENTIAL JOB FUNCTIONS:

?  Compile relevant claims matrices and reports for Executive and Operational Management.

?  Compile statistical results for the Proposal Development Department annually or on an as needed basis.

?  Assist in the design and maintenance of database applications specific to the needs of Claims Operations.

?  Assist with the PDM Claims Data submission and premium enhancement process.

?  Coordinate data requirements for all Federal and State of Florida regulatory audits to include HEDIS, NCQA, and CMS.

?  Assist in the development, approval and communication of all Claims Administrative Procedures (CAPs)

?  Assist with research and identification of CMS Claims Compliance issues.

?  Participate and assist in coordinating the auditing of all AvMed Claims Delegated providers.

?  Provide internal Claims analytical support.

?  Provide technical support to Department users.

?  Participate in identified Claims Department special projects as needed

?  Maintain a technological proficiency in order to identify and enhance Claims operations through new electronic innovations

?  Recognizes and observes all company and departmental policies and procedures.

?  Focuses on achieving departmental and organizational objectives

?  Maintains professional appearance by complying with dress code in an appropriate manner

?  Complies with company policies and procedures, which includes punctuality as they relate to work time, lunch, and break periods.

 

NON-ESSENTIAL JOB FUNCTIONS: 

?  Maintains strict confidentiality of department matters

?  Performs additional duties and responsibilities as assigned by management

 

CRITICAL SKILLS/EXPERTISE:

?  Ability to structure and prepare analysis to support decision-making.

?  Advanced skill level in the Microsoft Office Product suite (Excel, Word, PowerPoint, Access) and Business Objects and relevant health services research analytical programs.

?  Able to work effectively on teams.

?  Able to handle multiple functions and prioritize appropriately

?  Readily accepts and retains training and direction from management team.

?  Strong interpersonal skills and ability to interact with multiple departments and management.

?  Must be very creative and self-motivated.

?  Able to work in a fast-paced office and remain flexible

 

QUALIFICATIONS:

?  Bachelor degree in relevant field.

?  Previous data analysis or related experience in health related industry may be substituted for degree requirements.