Blue Cross and Blue Shield of Louisiana Medical Economics Analyst in Baton Rouge, Louisiana

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POSITION PURPOSE :

Independently researches, analyzes, develops, maintains and monitors the performance of new and existing, very complex reimbursement programs.

Designs system specifications that support claims payment and criteria for data bases that support analysis as well as training documentation describing programming, billing and payment guidelines for internal and external use.

Responsible for special reports and analysis, systems review and recommendations to support the implementation of new programs and/or process and procedure improvements for existing programs.

Assists Actuarial and Underwriting in setting premium rate relativities between network products. This is accomplished by creating models containing critical reimbursement components weighted by utilization.

Develops sophisticated financial modeling capabilities for the evaluation of reimbursement programs. Conducts financial modeling analyses under different reimbursement scenarios, identifies weaknesses and develops programs to address weaknesses.

Serves as primary technical reimbursement specialist for complex and/or special cases.

Analyst in the Provider Reimbursement Department are also responsible for: Coordinating reimbursement analysis for provider negotiations; Assisting Actuarial and Underwriting in setting premium rate relativities between network products. This is accomplished by creating models containing critical reimbursement components weighted by utilization.

Analyst in the Payment and Data Integrity Department are also responsible for: partnering with management to ensure business intelligence data, reporting solutions and analysis are an excellent fit for their evolving needs; analyzing data and processes and taking corrective action to ensure the accurate, efficient and effective configuration of departmental data bases and the dissemination of business information.

Accountable for complying with all laws and regulations that area associated with assigned duties and responsibilities.

NATURE AND SCOPE :

Position Location :

This position can report to either of the following.

Director of Facility Reimbursement

Director of Professional Reimbursement

Director of Payment Innovation

Director Payment and Data Integrity

Activities of Direct Reports :

This position has no reports, but has direct access to reimbursement specialists and/or provider audit staff.

NECESSARY CONTACTS :

In order to effectively fulfill this position the incumbent must be in contact with:

All levels of internal personnel, with primary contacts in Reimbursement, Provider Audit, Network Administration, IT, Medical Management, Benefits Administration, Actuarial, Legal, Executive, Marketing, and Underwriting. Providers, provider representatives, consultants, provider specialty organizations, AMA, vendor reps, and hospital administrators to exchange or review program information. Other data sources are market research consultants, AMA, St. Anthony, Relative Value Studies for Dentists, Dun and Bradstreet and HIAA, CMS, Blue Cross and Blue Shield Association, Blue Cross and Blue Shield Plans, sales and marketing regional offices.

QUALIFICATIONS :

A bachelor’s degree in statistics, accounting, finance, mathematics or related field analytical is required. Four years of experience in health insurance reimbursement, auditing, provider contracting, and/or financial analysis can be used in lieu of a degree. An MBA, ISDS, MHA, ASA or CPA is required. Three years related experience will be accepted in lieu of MBA, ISDS, MHA, ASA or CPA. Pursuit of coding (CPC or CPHC) designation preferred.

Three years of provider contract financial analysis and/or reimbursement program implementation experience is required.

Knowledge of reimbursement administration systems is required.

Requires excellent analytical and problem solving skills with demonstrated experience conducting research, locating and extracting appropriate enterprise-wide data from databases, developing business intelligence reports, analyzing and interpreting data, and providing summary report recommendations.

Proficiency with Microsoft Office Software. Requires advanced MS Excel experience as we as a minimum of two years of extensive experience using at least one of the following Microsoft software applications: Access (with Visual Basic for Access), SQL Server and/or SQL Service Reporting Services (SSRS) for building complex queries and statistical reports (e.g. dashboards, scorecards, etc. and performing advanced functions within these applications (e.g. macros; triggers; stored procedures and the efficient and effective configuration of department databases, reports, etc. Prefer experience using SAS and Microsoft SharePoint.

Demonstrated excellence in reimbursement program/system design and development is required.

Thorough knowledge of provider operations and procedures.

Strong knowledge of managed care processes.

Requires excellent presentation, oral/written communication, public speaking, interpersonal and negotiation skills and the ability to effectively partner with all levels of technical and non-technical business staff.

Health Plan Operations, Data Quality Assurance, Trizetto Facets/NetworX and/or Process Assurance Experience is preferred.

ACCOUNTABILITIES & ESSENTIAL FUNCTIONS :

Serves as provider reimbursement technical advisor and/or committee participant/chairperson to Information Technology staff, Benefits Administration staff, Provider Audit, Network Administration staff, and entry level Reimbursement Analyst by developing and implementing project/program narratives and responding to concerns on new and existing reimbursement programs, billing guidelines, and system requirements to ensure accurate implementation and maintenance of provider reimbursement programs.

Identifies claims and provider reimbursement related system problems, including claims coding and processing issues, coordinates research, conducts data quality/integrity audits; and in conjunction with Provider Audit, implements and monitors process, procedure and system changes designed to support departmental reporting.. At management’s direction, collaborates with IT and other business stakeholders to ensure the accuracy and meaningfulness of database information used for strategic planning initiatives.

Leads in the research, design, implementation, and maintenance of very complex hospital or professional provider reimbursement programs for traditional and managed care programs. Contact other plans, consultants, and local providers to assist in program specifications. Proactively monitors health care and health industry developments, including CMS/Medicare. Analyzes and produces management reports to monitor effectives and identify and resolve deficiencies of reimbursement programs in comparison to industry benchmarks, competitors, and Medicare.

Leads in the development of complex financial pricing models and financial data analysis to support modifications to reimbursement programs and monitor effectiveness of pricing logic.

Develops and issues a variety of statistical reports containing provider utilization trends, billing patterns, reimbursement issues, etc. to Network Administration, Medical Management, and Marketing to support internal strategies and external customer needs, such as contract negotiations and marketing efforts.

Complies with Corporate Objectives on project implementation and schedule deadlines. Ensures proper workflow by assessing reimbursement processes and recommending improvement as well as coordinating projects and time frames with less senior reimbursement staff.

Assists Actuarial and Underwriting in setting premium rate relativities between network products. This is accomplished by creating models containing critical reimbursement components weighted by utilization.

Assists with the decision-making process for identifying, selecting and modeling solutions to meet needs, goals, and metrics identified by operations and/or other analyst.

The physical demands described here are representative of those that must be met by an employee to successfully perform the accountabilities (essential functions) of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.

• Job duties are performed in a normal and clean office environment with normal noise levels.

• Work is predominately done while standing or sitting.

• The ability to comprehend, document, calculate, visualize, and analyze are all required.

An Equal Opportunity Employer

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Company Mission

To improve the health and lives of Louisianians.

Company Vision

To be the market leader that delivers unsurpassed value to our customers through partnerships across the healthcare system.

Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity company and is an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of Louisiana is licensed to sell products only in the state of Louisiana.