Health Plan Claims Reporting Analyst (REMOTE IN TEXAS)

Overview:

As the Health Plan Claims Reporting Analyst for a Health Maintenance Organization (HMO) and other Health Plans based in Texas, you will implement within the claim management system software and other resources the reporting development and management. This position will also provide support to the Claims Management and Configuration Team, along with coordination of Health Plan Departments to provide information as needed.    

Essential Functions:

Report Design: Collaborate with Health Plan Departments to develop ad-hoc and additional standardized reports within the claims management software system. 

Reporting for Health Plan Departments: 

• Prepare Finance Data Claims Reports (IBNR, Check Register, Utilization, and others)
• Prepare Network Data Reports (Value Based Provider monthly reports and others)
• Prepare and Coordinate with Health Plan Departments required Compliance Reports (quarterly and annual reports)
• Prepare Client Reports as needed (Weekly Claims Reports, Monthly Void and Refund, and others)

Assist the Health Plan Director of Claims Administration and Configuration:

• System Enhancements and Training: Attend training sessions with the claims management system software vendor to understand system changes and enhancements. Train Health Plan Departments on claims management system software changes that affect their functionality. 
• Vendor Coordination: Coordinate with outside vendors to ensure their resources are managed to meet standards of operations within the claims management system software. 
• Compliance Coordination: Coordinate with the Health Plan Compliance Department to ensure that the claims management system software meets all regulatory requirements.

Support the Configuration Team with:

• Plan Design Configuration: Manual non-automated updates and creation of benefit plans in the claims management system software based on plan design provided by the Health Plan Benefit Team.
• Provider Contract Configuration: Manual non-automated updates and creation of the contracted Provider’s fee schedule in the claims management system software provided by the Health Plan Provider Network Team.
• Claims System User Management: Managing the Users and their Permissions within the claims management system software.
• Enrollment Management: Manual non-automated updates of the enrollment configuration to support the Health Plan.
• Health Plan Department Coordination: Collaborate with Health Plan Departments, such as Clinical, Operations, Member Services and Financial to develop processes to support their needs from the claims management software system.

Knowledge, Skills, and Abilities

• Strong understanding of healthcare claims systems processing principles, coding systems, and reimbursement methodologies.
• Proficiency in utilizing claims processing software and systems (VBA preferrable), with a track record of driving system enhancements and process improvements.
• Excellent communication, and interpersonal skills, with the ability to coordinate with Health Plan Departments to achieve organizational goals.
• Thorough knowledge of healthcare regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations.
• Analytical mindset with the ability to interpret complex data, identify trends, and implement data-driven solutions.
• Demonstrated ability to effectively manage multiple priorities in a fast-paced environment while maintaining attention to detail and accuracy.

Minimum Education:

• Bachelor's degree in Healthcare Administration, Business Management, or related field (preferred but not required).
• High School Diploma required.

Minimum Experience:

• Minimum of 3 years of experience in health plan claims systems processes, preferably within an HMO or managed care environment.

• 3 years Minimum 3 years of experience with SQL based reporting management tools