Job Description

The Business Analyst (BA) of Claims is responsible for forming, building and maintaining connections with the Client to help drive results for the third-party administration (TPA) of Claims Operations. In this role, the BA of Claims will provide client advice, build rapport, run reports on performance data and production and provide timely responses to their inquiries as it relates to various aspects of claims processing. In addition, BA of Claims will conduct research on escalated items, monitor requests, and run ad-hoc reports as needed. The BA will interface and report into our Tampa Claims Operations. This role is required to work in the office, 5 days a week for the first 3 months of employment. Depending on performance, the role would then be eligible for Hybrid work, in office for 3 days a week.

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Relationship Managemen

• Build and improve relationships with customers, key suppliers and partners.
• Coordinate the review and response of Provider and member escalations; meeting all Department of Labor and customers requested guidelines for accuracy, timeliness and documentation.
• Work with other responsible teams to assist in the research and response to complaints. Teams may be internal or external.
• Work with internal departments to ensure the company meets the customers’ expectations.
• Respond to customer emails promptly and follow up on response and escalation matters as needed. Address customer complaints and resolve issues efficiently.
• Identify and close early warnings (risks) on projects to avoid any customer escalations.
• Creates formal networks with key internal and external decision makers

Delivery Management

• Process and adjudicate claims and claims adjustments.
• Provide GetNext oversight and direction to stay on top of HICS L1, HICS L2, and DOI pending’s and clearing of aged items.
• Communicate changes, enhancements, and modifications of business requirements — verbally or through written documentation — to the customer, project managers, and other stakeholders so that issues and solutions are understood.
• Follow all HIPAA guidelines for the release of information.
• Work directly with the Offshore team regarding NERD feedback and Standard Operating Procedure (SOP) updates.
• Generate daily activity reports and support Operational meeting reporting for the customer, provide month end reporting and any other required reporting needs.
• Plan and conduct Operational meetings, customer QBR or other sessions as required
• Conduct regular customer connects (meetings/visits/video-conference) and participate in Management Review Meetings (MRM) to understand the customer’s current and future needs and seek feedback to improve the delivery methodology, timelines, resource allocation, etc.
• Liaise between the customer and internal delivery teams to understand operational requirements, goals, and drive project health by adhering to organizational norm of project metrics. Work with internal departments (IT, Finance, Account Executives, etc.) and stakeholders to deliver solutions.
• Achieve quality and member satisfaction goals.
• Partner with the Account Executive, Account Manager(s) and other key stakeholders to develop an operational roadmap, based on the customer’s needs, driving continuous improvement in customer satisfaction, member satisfaction and operational efficiencies.
• Understand customer needs, both internal and external, and look for opportunities to provide the highest quality service.
• Lead project planning and process updates.
• Proactively evaluate alternative solutions, recommend actions, and develop strategies to maximize customer success.
• Apply analytical techniques to research issues, integrate complex data, synthesize results, evaluate data quality, and identify critical process variables. Use findings to make decisions, identify gaps, and offer recommendations.
• Design and monitor project performance dashboards/reports for the customer.
• The BA will serve as a backup and complete production packages to ensure SLA/KPI are met.
• Ensure 100% compliance to project SLA’s, information security protocols, etc. (all customer contractual obligations).
• Monitor and take appropriate actions on internal and/or external audit finding sto ensure no major non-compliance/deviation from the SLA

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Qualification/ Experience Requirements

• Excellent conflict resolution and interpersonal skills and the ability to build lasting relationships with customers.
• Excellent organization and prioritization skills, with a strong work ethic. Highly detail oriented.
• Excellent facilitation, follow-up and documentation skills.
• Exceptional analytical and conceptual thinking and problem-solving abilities Demonstrates proficiency in eliciting, analyzing, and documenting requirements – business and technical for stakeholders.
• Ability to lead and work within a team.
• Sound problem-solving and decision-making skills to troubleshoot customer issues and concerns.
• Knowledge of Claims Processing, Benefit plan interpretation.
• Strong oral and written communication skills. Above average numeric skills, including ability to reconcile statements and discrepancies.
• 834 trained with processing knowledge, SME on processing procedures with the ability to assist with working production queues as needed.
• Advanced skills in Microsoft Office suite: Outlook, Excel, Word, and PowerPoint.
• Conceive, plan, and execute projects related to the strategic needs of the company.
• Provides continuous flow of complex information and work results to higher levels.
• Must be familiar with the insurance industry.
• Demonstrates flexibility and resilience when faced with multiple demands, shifting priorities, ambiguity and rapid change.
• Maintains confidentiality.
• Work Independently.
• Ability to understand & follow statutory, regulatory and contractual requirements, verbal instructions, and written policies and procedures.
• Strong interest in, and knowledge of, federal health policy, particularly regarding national healthcare reform and Exchanges.
• Experience interpreting and implementing federal regulations, and experience translating regulations into business requirements, strongly preferred.

Education:

• 5 year’s experience working in the Healthcare environment.
• Bachelor’s degree in business or related field preferred.