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Senior Claims Analyst, Benefits Medical Programs

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Date: Nov 29, 2017

Location: Houston, TX, US

Company: Houston Independent School District

Senior Claims Analyst, Benefits Medical ProgramsJobID: 46455
Position Type:
Closing Date:
12/02/2017
Business Professionals/Benefits
Date Posted:
10/2/2017
Department:
Benefits
Date Available:
11/01/2017
Location:Area:Job Category:
Hattie Mae White Bldg.NorthwestBusiness Professionals
Job Code:Contract Type:Months:
30003084None12
Salary Minimum:Salary Maximum:
$53,595$71,013

Attachment(s):
  • Senior Claims Analyst, Benefits Medical Programs- FA0745
POSITION TITLE: Senior Claims Analyst, Benefits Medical Programs

CONTRACT LENGTH: 12M

DATE: 06/08/16

DATE OF LAST REVISION: 06/08/16

Job Code: FA0745

PAY GRADE: 29

FLSA EXEMPTION STATUS: E

Job Family – Finance & Accounting

JOB SUMMARY: The Senior Claims Analyst, Benefits Medical Programs is responsible for the monitoring and review of employee medical and pharmacy programs for 20,000 employees enrolled in one of the HISD medical plans. This analyst reviews both medical and pharmacy claims to determine if charges are appropriate and within the contracted amounts.

MAJOR DUTIES & RESPONSIBILITIES:

List most important duties first

1. Downloads daily check register from medical plan administrator and review large claims with medical TPA to determine if payments were appropriate and within contract terms and conditions. Audits claims daily for plan eligibility by member. Documents findings and maintains issue log on all identified issues

2. Manages identified claim and eligibility issues with medical administrator. Determines root cause issues and develop recommendations for process improvements as necessary. Reviews large claims monthly with administrator. Reviews monthly medical plan costs with consultant and administrator reports. Identifies areas of concern and discusses them with Sr. Manager, Benefits Medical Programs and administrator. Develops and maintains regular reports on claim program performance. Reviews case management and other medical plan administrator services for potential problems, solutions, and resolution.

3. Develops vendor expectation measures and regularly meets and reviews with medical plan administrators, pharmacy plan administrators, and other related medical plan vendors to ensure that vendors are performing at a high level. Prepares summary reports on vendor performance for senior management

4. Downloads monthly detailed claim report and reviews claims with administrator for potential issues. Monitors that specialty pharmacy, pre-authorizations, step therapy, zero cost medications and other plan features are being administered correctly. Audits members to ensure plan eligibility. Documents findings and maintains issue log on all identified issues.

5. Manages identified claim and eligibility issues with pharmacy administrator. Determines root cause issues and develop recommendations for process improvements as necessary. Reviews large claims monthly with administrator. Reviews quarterly pharmacy plan costs and reports with consultant and administrator. Identifies areas of concern and discusses them with Sr. Manager, Benefits Medical Programs and administrator. Develops and maintains regular reports on claim program performance.

6. Develops and produces regular monthly, quarterly and annual reports on medical and pharmacy costs. Analyzes and reports findings to Sr. Manager, Benefits Medical Programs. Assists in the development of report and presentation materials.

7. Processes all Medicare COB demands for the medical plan. Identifies claims for potential Medicare Primary issues and ensure claims where Medicare is primary are processed correctly. Reviews subrogation activities by the plan administrators.

8. Stays current in medical billing and pharmacy billing practices. Keeps abreast of changes in related benefit laws and regulations, such as the Affordable Care Act, HIPAA, COBRA and others.

9. Performs other job-related duties as assigned.

EDUCATION: Bachelor’s Degree

WORK EXPERIENCE: 3 to 5 years, Have a proven track record in reviewing complex medical and pharmacy claims. Successful candidates will demonstrate a proficiency in medical and pharmacy program claim systems and review. Very familiar with local medical community billing practices and pharmacy billing practices.

TYPE OF SKILL AND/OR REQUIRED LICENSING/CERTIFICATION: Highly skilled in reviewing both medical and pharmacy claims to determine if charges are appropriate and within the contracted amounts. Able to work in a fast-paced work environment and meet critical deadlines. Highly detailed individual to ensure critical and sensitive data integrity and ability to spot data errors and system flaws for correction. Critical thinking skills, root cause analysis, problem resolution, project management, confidentiality, ethics, judgment and decision-making, results oriented. MS Excel, MS PowerPoint (Develop presentation slides), MS Access – basic use and query writing, PeopleSoft, SAP, Microsoft Office,Office equipment (e.g., computer, copier)

LEADERSHIP RESPONSIBILITIES: No supervisory responsibilities. May provide occasional work guidance, technical advice and training to staff.

WORK COMPLEXITY/INDEPENDENT JUDGMENT: Work is substantially complex, varied and regularly requires the selection and application of technical and detailed guidelines. Independent judgment is required to identify, select, and apply the most appropriate methods as well as interpret precedent. Position regularly makes recommendations to management on areas of significance to the department. Supervision received typically consists of providing direction on the more complex projects and new job duties and priorities.

BUDGET AUTHORITY: Analyzes and interprets data and figures.

PROBLEM SOLVING: Decisions are made on both routine and non-routine matters with some latitude, but are still subject to approval. Job is occasionally expected to recommend new solutions to problems and improve existing methods or generate new ideas.

IMPACT OF DECISIONS: Decisions have moderate impact to the facility/department or division, causing increased satisfaction or dissatisfaction; producing efficiencies or delays; promoting or inhibiting personal intellectual or professional development; and/or contributing to financial gain or expense. Errors may be serious, usually not subject to direct verification or check, causing losses such as improper cost calculations, overpayment or improper utilization of labor, materials or equipment. Effect usually confined to the organization itself and is short term.

COMMUNICATION/INTERACTIONS: Information sharing – gives and receives information such as options, technical direction, instructions and reporting results. Interactions are mostly with customers, own supervisor and coworkers in own and other departments.

CUSTOMER RELATIONSHIPS: Takes routine or required customer actions to meet customer needs. Responds promptly and accurately to customer complaints, inquiries and requests for information and coordinates appropriate follow-up. May handle escalated issues passed on from coworkers or subordinates.

WORKING/ENVIRONMENTAL CONDITIONS: Work is normally performed in a typical interior work environment which does not subject the employee to any hazardous or unpleasant elements.
Ability to carry and/or lift up to 15 pounds




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