Verda Healthcare, Inc. has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan for 2024. We are looking for a Business System Analyst to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare health plan is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare Health and we will support you all the way.
Position Overview
The Business System Analyst is responsible for developing an in-depth understanding of the underlying data and proper business uses to translate end-user data and information requirements into a format to aid various Verda teams in drawing insight from that data. This includes creating queries, visualizations, algorithms, and reports. Also, the Business Systems Analyst is responsible for the activities related to system configuration and health plan implementations, for accurately interpreting specific Health Plan Benefits, Contracts, and Payment Rates as well as additional business requirements and converting these terms to configuration parameters. This position is also responsible for coding, updating, and maintaining provider contracts, fee schedules and various system tables through the user interface.
The Business System Analyst is responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data from other claims systems and the application of business rules as they apply to each database. Validate data to be housed in provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management, and credentialing. On will also serve as an auditor for provider data loads and updates.
Job Description
- Develop and implement databases, data collection systems, data analytics and other strategies that optimize statistical efficiency and quality.
- Manages all business activities involving system development and implementation, provider, and hospital contract configuration, coding compliance and fee schedule implementation.
- Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases.
- Work collaboratively across the organization to address business needs, determine configuration changes needed and how the changes impact other areas.
- Validate data to be housed on provider databases and ensure adherence to business and system requirements as it pertains to contracting, network management, and credentialing.
- Perform Fee Schedule and Benefit QC to ensure the system is set up correctly before being released into production.
- Audits loaded provider records for quality and financial accuracy and provides documented feedback.
- Reviews current benefit and DOFR configurations and suggests improvement processes to ensure systems are working more efficiently and improve quality.
- Troubleshoot system related issues and analyze business needs, determine necessary configuration, and develop test scenarios to ensure accurate and complete testing.
- Generates Provider Related reports to facilitate and support Provider Services/Provider Problem Research & Resolution.
- Generates and distributes Network Related Compliance/Regulatory/Accreditation reports.
- Assists in configuration issues and loading of provider information, as needed.
- Research and resolve claim/ issues, pended claims and update system as
- Supports Claims staff with complex claims
- Special Project as assigned
- Ability to travel
Minimum Qualifications
- Bachelor’s degree preferred in Computer Science, Healthcare Administration, or related field
- Master’s Degree or equivalent preferred
- 3-5+ years’ experience in configuration/benefits and/or medical claims processing.
- Experience with bundled payment contracting or risk and capitation required
Professional Competencies
- Proficient in Microsoft Suite (Excel, PowerPoint, Project, Outlook, Word, Visio, etc.)
- Extensive experience in SQL
- Experience with the end-to-end claims processing
- Knowledge of medical terminology, ICD-10, CPT and HCPCS.
- Understand all relevant payment methodologies, including but not limited to Medicare, RBRVS, DRG, APR-DRG, OPPS, Per Diems, Capitation, and Case Rates.
- Strong analytical skills with the ability to collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.
- Understands and can construct financial responsibility tables and check for accuracy against Health Plan Documents.
- Understands how to build/maintain Benefit Rules & Benefit Records (Detail Option Records).
- Understands how to translate Health Plan EOC’s into system Benefit Tables.
- Ability to manage and prioritize multiple tasks, promote teamwork and fact-based decision making
- Communication skills
- Ability to work independently and within a team environment
- Familiarity of the healthcare field
- Critical listening and thinking skills
- Training/teaching skills
- Decision making/problem solving skills
- Resiliency in a changing environment
- Demonstrated progression of leadership and responsibility
- Ability to work in a fast-paced, start-up culture
- Proven ability to build, develop, and lead strong teams of operators
Supervisory Responsibilities. This job has no direct supervisory responsibilities but will be required to perform as a team leader and act as a backup for the team’s manager.
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
Job Type: Full-time
Benefits:
- 401(k)
- Dental Insurance
- Health insurance
- Life insurance
- Paid time off.
- Vision insurance
Schedule:
- 8-hour shift
- Monday to Friday/Weekends as needed
Ability to commute/relocate:
- Reliably commute or planning to relocate before starting work (Required)
PHYSICAL DEMANDS
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
*Other duties may be assigned in support of departmental goals.