Job Description: About the Mission of this role:
Claims auditing is a core function of health plan payment integrity operations, but many payment integrity departments lack the ability to track and manage inventory effectively, and others struggle with disparate processes or workflow solutions that require custom builds and integration workarounds into claims platforms.
Our proprietary workflow application, EXLMINE™, is a robust payment integrity system, supporting both pre-payment and post-payment modalities, and is designed to help audit staff to identify, manage, and act on potential improper claims payments. The system improves effectiveness and efficiency by centralizing all functions needed to manage the entire life cycle of an audit from data intake to overpayment recovery to reconciliation and reporting.
EXLMINE™ centralizes all claims audit processes on a single platform, delivering an intelligent experience for claim workflows and inventory management. The EXLMINE™ platform is highly configurable, customizable to meet the demand of any data mining or audit program to support our clients’ business needs.
The Business Analyst is a key role to ensure to ensure requirements are captured to design workflows and provide solutions to internal stakeholders and provide the implement the tools required in EXLMINE.
Functional Responsibilities:
- Collaborate with key stakeholders (internal and in some cases, external client partners) to capture and define business requirements that will identify and solve the immediate challenge.
- Lead the effort to develop and document business requirements, business process flows, supplement specification, and resolve requirement issues for large-scale, cross-divisional complex projects.
- Lead and document discovery sessions with business owners and subject matter experts to design and develop standard workflows in EXLMINE application adhering to EXL Standards.
- Design and maintain letter templates for all correspondence in the EXLMINE application software.
- Partner closely with various business units and clients to identify and validate new opportunities by collecting and validating critical data for analysis.
- Actively perform triage, testing, and root cause analysis to validate proposals using pertinent data and facts.
- Review system fields and provide field-level data mapping to the Reporting Hub (Enterprise Data Warehouse) for operational reporting.
- Review, understand, and document the current operational processes and data sources to establish support for current and future reporting requirements.
Coach and mentor other Business Analysts in the team.
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Knowledge and Skills Requirements:
- The candidate is expected to demonstrate strong experience in hands-on data analysis of healthcare databases, including EHR / EMR claims of either Payer’s or Providers.
- Ability to understand the system architecture and provide solutions to meet the business needs.
- Strong knowledge of software development life cycle with different methodologies.
- Knowledge in SQL for querying the underlying data in the system for analysis.
- Proficient in the analysis of data and the use of process visualization software.
- Excellent attention to detail and the ability to work independently without supervision, be self-directed and demonstrate initiative.
- Effectively understand claims data payment process and the roles of payer and provider intersection.
