PacificSource Health Plans

Senior Research Analyst

US-OR-Eugene
Job ID
2017-332
Type
Regular Full-Time
Hiring Pay Range
$17.50-$21.50
# of Openings
1
Status
Non-Exempt

Overview

Review, analyze and process complex hospital and medical claims.  Research and resolve grievance and appeals which need a higher level of adjudicator expertise, clinical interpretation and decision making, for all lines of business.  Contribute to establishing and/or revising claims research policies and procedures and look for ways to improve processes.  Work with external vendor(s) contracted to do claims analytics.  Will be required to participate in the Analytic claims work group as well as the FWA work group and may be called upon to participate on other standing or ad hoc workgroups.

Responsibilities

  1. Analyze quarterly claims reports, looking for savings opportunities, training opportunities and FWA by;
  • Reviewing data for patterns
  • Requesting medical records
  • Review of records and developing recommendations
  • Collecting data and present findings to the Claims Leadership Team.
  1. Work cooperatively with the Legal and Compliance grievance personnel to review research and make a determination to approve or uphold the claims processing based on PacificSource policy and procedures, group/individual contracts and applicable laws governing claims processing.
  2. FWA- Log and research leads of possible fraud waste or abuse. Make recommendations for resolution and work with the FWA workgroup across all lines of business.
  3. As needed, process claims received through the Advanced Rebill queue and the Compliance queue. These claims require additional research, including, but not limited to the following;
  • Initial clinical evaluations
  • Request and review of medical records
  • Coding assistance and research- CPT and ICD-9/10, including unlisted procedures and changes in diagnosis and procedures.
  • System editing review.
  1. Assist with Claims processing as needed
  2. Report pertinent information back to the Claims Leadership Team.
  3. Maintain Certifications in Medical Coding and/or Medical Records Auditing by attending needed CE credits.

Supporting Responsibilities:

  1. Interact with business leaders and users, including external partners and customers as required.
  2. Maintain professional, service oriented relationships.
  3. Develop and track project plans for large upcoming projects that affect multiple areas.
  4. Collaborate with other areas on cross functional tasks.
  5. Lead and participate in special projects and committees as assigned.
  6. Ability to judge severity of problems and the need to escalate to management or employ external services.
  7. Demonstrate ability to organize and prioritize work.
  8. Demonstrate ability to work independently with minimal oversight.
  9. Meet department and company standards of performance, attendance and regularly attend team, department and company meetings/huddles.
  10. Perform other duties as assigned.

Qualifications

Work Experience: Minimum five years claims adjudication at a claims level III or comparable experience.  Advanced skills in medical terminology, CPT and ICD9/10 coding.

 

Education, Certificates, Licenses: Requires high school diploma or equivalent.  Certified as a Medical Claims Coder and or Certified Medical Records Auditor.

 

Knowledge: Research skills and ability to evaluate situations for appropriate resolution. Ability to read and understand health contracts, benefit language, medical records from both professional and institutional sources.

 

Has a thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology.  Has a basic working knowledge of Oregon Insurance Division rules and regulations.  Moderate/high clinical interpretation skills.  Thorough understanding of claims processing system and operation.  Experience using Microsoft Word/Excel.  Advanced keyboard and ten-key skills.  Ability to work under time constraints and to quickly understand new information.  Team player willing to collaborate with others and help accomplish objectives.  Meet or exceed PacificSource performance expectations.

 

Competencies

Our Values

  •   Building Customer Loyalty
  •   Building Strategic Work Relationships
  •   Continuous Improvement
  •   Adaptability
  •   Building Trust
  •   Work Standards
  •   Contributing to Team Success
  •   Planning and Organizing

 

 

  • We are committed to doing the right thing. 
  • We are one team working toward a common goal. 
  • We are each responsible for customer service.  
  • We practice open communication at all        levels of the company to foster individual, team and company growth.  
  • We actively participate in efforts to improve our many communities-internally and externally.
  • We encourage creativity, innovation, and the pursuit of excellence.

 

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

 

Physical Requirements:  Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

 

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

 

PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

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