Benefits Analyst (Claims Focused Analyst)

Overview: The Benefits Analyst will be responsible for providing in-depth analysis and creation of healthcare provider business rules that will modify and edit medical claims. This role requires in-depth knowledge of medical billing and coding of insurance claims from working in the healthcare profession as either a biller or at a software clearinghouse. The Analyst role is a customer facing role via email, ticketing, and occasionally in video meetings.

This role requires the ability to review customer requests, ask for any clarifications from the requester and then create, test and publish custom claim edits on behalf of the client within company stated SLAs with a high level of quality. Requests can be customer initiated or medical insurance company mandates or necessary to ensure claims are paid timely. In addition, the Analyst will be responsible for reviewing claims that have failed to process in the system and come up with new edits to solve for outstanding changes that are needed within the system.

The Analyst will work as part of a team to ensure that the Inovalon clearinghouse system maintains a high level of first pass claims acceptance rate through continued monitoring and proactive research to the changing needs of insurance claims processing.

Duties and Responsibilities:

• Take ownership of triaging incoming internal and external customer requests for medical claims processing changes needed.


• Prioritize requests based on operational needs and escalate issues to quick resolution when needed.


• Implement technical business rules for processing medical claims; including building logic statements based on specific medical insurance claims fields to modify and or change; test with medical claims and implement to live systems.


• Take a collaborative role with the application support team to triage production problems involving claims processing, perform defect analysis and provide fixes in business logic to be implemented by software teams in a timely fashion, particularly with high priority items.


• Work collaboratively with other Inovalon departments to ensure fit for purpose solutions are delivered.


• Liaise with Technology and Engineering teams to resolve application issues and enhancement requests to internal tools used by the team to expand capabilities.


• Ensure compliance to Company procedures when making changes and implementing new business rules.


• Ensure ongoing regularly scheduled updates required for compliance are executed timely.


• Responsible for accessing payer websites and compliance standards research (i.e. UB Editor, payer Companion Guides)


• Review claim level and file level failures or errors ongoing to find and implement new rules as needed to ensure our first pass claim acceptance rate hits our internal goals.


• Update documentation, SOPs, and training documentation as needed.


• Maintain a follow up schedule for unresolved issues.


• Respond to support requests through phone calls, and emails.


• Assist operations with process improvement and finding solutions to business problems.


• Maintain compliance with Inovalon’s policies, procedures and mission statement.


• Adhere to all confidentiality and HIPAA requirements as outlined within Inovalon’s Operating Policies and Procedures in all ways and at all times with respect to any aspect of the data handled or services rendered in the undertaking of the position;


• Fulfill those responsibilities and/or duties that may be reasonably provided by Inovalon for the purpose of achieving operational and financial success of the Company.


• Uphold responsibilities relative to the separation of duties for applicable processes and procedures within your job function.


• We reserve the right to change this job description from time to time as business needs dictate and will provide notice of such. 

Job Requirements:

• Required: Minimum 2 years’ experience with Medical Billing in a healthcare setting, doctor’s office or hospital; Preferred: Clearinghouse backend operations.


• Understanding of Medicare NCDs, as well as Medicare/Medicaid MUE and CCI related billing rules


• Solid understanding of Institutional and Professional claim forms, 5010 X12 files including 837, 835, 277 and 999.


• Nice to have: experience in application support, SaaS experience preferred, healthcare background preferred


• Being able to communicate clearly with clients; client focused and sensitive to client needs


• Experience working with a ticketing system; Preferred: Service Now


• Direct experience building logic rules for medical claims processing.


• Excellent problem solving and analytical skills.


• The ability to multi-task effectively

Education:
Bachelor's degree or equivalent work experience required.

Physical Demands and Work Environment:
Sedentary work (i.e., sitting for long periods of time);
Exerting up to 10 pounds of force occasionally and/or negligible amount of force;
Frequently or constantly to lift, carry push, pull or otherwise move objects and repetitive motions;
Subject to inside environmental conditions; and
Travel for this position will include less than 5% locally usually for training purposes.