19 days old

Healthcare Coordination of Benefits (COB) Data Mining Analyst

Sunrise, FL 33351
Regular Full Time
   

Responsibilities:

The Healthcare Coordination of Benefits (COB) Data Mining Analyst is responsible for objectively and accurately complete claim audit reviews on assigned audits while meeting quality and productivity performance goals.  This position makes determinations based on claims payment expertise and knowledge while using audit tools and resources available.  Communicates and supports the identification of additional data mining opportunities and participates in development of ideas as necessary. Able to contribute to resolution of more complex issues or client requirements, and may supporting training and guidance to other Audit Recovery Analysts.

  • Conducts COB investigations and associated claims reviews and determines if claims are appropriately paid in accordance with COB rules, CMS regulations and applicable laws and policies.
  • Documents findings within audit tracking system and maintains thorough and objective documentation of findings
  • Investigates, researches, and analyzes claims data, applying knowledge of medical or pharmacy policy to determine proper order of benefits with other payers, both Medicare and commercial. 
  • Creates narrative rationale to correspond with audit determinations
  • As needed, supports findings during the appeals process
  • Serves as a senior claims payment resource; provides claims payment expertise, and claims payment guidance to the team
  • Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse
  • Monitors, tracks and reports on all work conducted 
  • Consults with our clients, data anlaysts, other claims payment resources and contractors as necessary
  • Maintains current in depth knowledge of changes in technology, practice and regulatory issues that may affect our clients
  • Proactively contributes to process improvement activities and sets positive example for group participation and takes ownership in improvement initiatives
  • Actively contributes in quality assurance functions, development of member investigation guidelines and training
  • Proactively identifies and recommends opportunities for cost savings and improving outcomes
  • Serves as positive role model and example for other Audit Recovery Analysts
  • May supporting training and guidance to other Audit Recovery Analysts
  • Attends conference calls and meetings as requested
  • Complies with company policies, processes and procedures
  • Successfully completes, retains, applies and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position
  • Demonstrates Performant core values in performance of job duties and all interactions
  • Performs other duties as assigned

Required Skills and Knowledge:
  • Strong working knowledge of coordination of benefits and medical claims processing
  • Depth of knowledge of insurance programs, particularly the coverage and payment rules
  • Demonstrated ability to apply breadth and depth of applicable business and industry knowledge to developing approaches to customer data mining opportunities as well as continuous improvement initiatives
  • Ability to be flexible and seizes the opportunity to cross train
  • Ability to maintain high quality work while meeting deadlines and performance metrics
  • Excellent organizational, interpersonal and communication skills
  • Demonstrated ability to resolve complex problems 
  • Ability to serve as a positive role model to more junior staff members
  • Demonstrated ability to train and support team members with less experience with positive interaction and results
  • Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings
  • Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members
  • Acute sense of professionalism and confidentiality
  • Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel)
  • Intermediate level of proficiency with Microsoft Excel, Word and Access
  • Capability of working in a fast-pace environment, flexibility with assignments and the ability to adapt in a changing environment

Physical Requirements
  • Sit/stand/walk 8-12hr/day
  • Lift/carry/push/pull under and over 10lbs occasionally
  • Keying frequency, handling, reaching, fine manipulation

Education and Experience:
  • Bachelors degree or an equivalent level of competence obtained through experience, education and/or training.
  • 3+ years of experience in the health care industry in eligibility or claims analyst type of function.
  • 3+ years of experience with claims processing systems such as UNET, COSMOS, NDB, TOPS, FACETS, AMYSIS, MHS, etc.
  • 3+ years working with large volumes of membership or eligibility data.
  • Experience with CMA shared data files and CAQH files preferred.


Other Requirements

*Must submit to and pass background check. Must not have any Federal or State liens resulting from County, State or Federal tax issues.  Must not have any current defaulted student loans.
*Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors.
*Must submit to and pass drug screen.

This job profile is subject to change at any time

Reasonable Accommodations may be made to enable individuals with disabilities to perform the essential functions.

Performant Financial Corporation is an Equal Opportunity Employer.

Performant Financial Corporation is committed to creating adverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.

NO AGENCY SUBMISSIONS


   


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Posted: 2021-03-25 Expires: 2021-05-13

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Healthcare Coordination of Benefits (COB) Data Mining Analyst

Performant Financial
Sunrise, FL 33351

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