Lead Business Analyst (Medical Policy) - Hybrid (PA/NJ/DE)
Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.
The Lead Business Analyst ensures accurate set-up of medical and claim payment policies in accordance with business requirements. The Lead Business Analyst reviews claims data and trends to determine if system enforcement is appropriate or requires adjustment, as well as identifying areas of improvement, system inconsistencies and training opportunities.
DUTIES AND RESPONSIBILITIES:
· Collaborate with team associates and peers to provide oversight of day-to-day work and improve business area processes and tasks.
· Develop policy enforcement requirements based on medical and claim payment policy criteria. Types of enforcement include but are not limited to claim system, prior authorization, desk level procedures, and post-payment review.
· Collaborate with internal business colleagues within the department to gain an understanding of policy criteria, and medical coding rules, to assess systems capabilities.
· Collaborate with other departments and external vendors to ensure the accurate implementation of policies according to business requirements.
· Identify policies that require manual review of policy criteria when systematic enforcement is not an option or not recommended.
· Provide timely documented feedback on issues identified at the system level and execute escalation procedures, including corrective action plans, as applicable.
· Provide quality assurance through development and review of claims data utilization reports to ensure assigned policies are enforced according to business requirements.
· Provide review and resolution of claims incidents resulting from policy set-up issues. Follow-through until all impacted claims are identified and adjusted and provide proper reporting.
· Perform root cause analysis to determine source of policy set-up issues.
· Perform User Acceptance Testing in collaboration with external vendor.
· Provides input to regulatory and other oversight teams regarding adherence to compliance requirements (e.g. CMS, BlueCard processing rules, Product Rules, denial messaging, member/provider liability).
· Interact with all levels of associates and management within the Company and with outside contractors, consultants and other organizations.
· Performs additional related duties as assigned.
QUALIFICATIONS:
· Bachelor's degree in relevant discipline or equivalent work experience.
· Current coding certification (CCS, CPC, RHIA, RHIT) desirable but not required
· Minimum of five years related Claims, Operations or Business Requirement Development experience.
· Must be able to work independently, prioritize workload, meet deadlines, and to assess the criticality of issues.
· Effective time management, shown through the ability to prioritize deliverables and communicate realistic timeframes for resolution.
· Strong problem-solving skills, with a key attention to detail.
· Solid written and verbal communication skills.
· Proven competency with various business tools, such as Microsoft Excel, Word, PowerPoint, SharePoint, and Teams.
· Working knowledge of the organization, business processes, and claims end to end process.
Hybrid
Independence has implemented a “Hybrid” model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the “Hybrid” model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Inclusion and Belonging
At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.