Claims Business Engineering Analyst

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Claims Business Engineering Analyst is responsible for creation, updates and implementation of documented claims processing procedures. The Analyst is also responsible for troubleshooting claims that are incorrectly processing and working with various departments like Payment Policy, Benefits, and Provider Enrollment etc. to assist in the resolution of these claims. The Analyst will work independently and within teams to achieve the desired results.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

• Research, troubleshoot and conduct root cause analysis for claims that are incorrectly processing.
• Responsible for maintaining the Business Engineering Queues and Roles within Facets along with the Business Engineering mailbox.
• Liaise between various business departments such as Payment Policy, Benefits Administration, Facets Configuration, etc.
• Gather information to create and/or update documented processes by observing claims processing.
• Create and update documentation for Claims Operations.
• Conduct meetings to review updates/changes/additions to Claims Operations procedures.
• Collaborate with the Learning & Development Team to develop material and support training classes.
• Conduct required UAT testing for all WellSense product lines.
• Test business processes and recommend improvements
• Identify automation opportunities
• Analyze claim data to determine root cause, trend, summarize findings and offer recommendations.
• Build reports as needed based on claim data analysis
• Other duties as assigned

Supervision Exercised:

• No direct reports

Supervision Received:

• Weekly supervision with Manager of Claims Business Engineering

Qualifications:

Education Required:

• High School Diploma
• Associates Degree or the equivalent combination of training and experience, and/or 3 - 5 years related experience.

Education Preferred:

• Bachelor's Degree

Experience Required:

• 5 + years claims experience; Facets preferred.

Experience Preferred/Desirable:

• Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
• Knowledge of Medicare and Medicaid programs.

Required Licensure, Certification or Conditions of Employment:

• Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Proficient in processing claims from multiple lines of business and claim types.
• Analytical skills and using mental reasoning or research to gain insight into or solve problems.
• Experience or skill with finding and analyzing patterns in data.
• Exceptional analytical and conceptual thinking skills.
• Advanced technical skills.
• Excellent documentation skills.
• Fundamental analytical and conceptual thinking skills.
• A track record of following through on commitments.
• Excellent planning, organizational, and time management skills.
• Effective collaborative and proven process improvement skills.
• Strong oral and written communication skills; ability to interact within all levels of the organization.
• A strong working knowledge of Microsoft Office products and Tableau Reporting
• Demonstrated ability to successfully plan, organize and manage projects
• Detail oriented, excellent proof reading and editing skills.
• Business Analysis - Knowledge of methods to analyze business needs and recommend relevant solutions including policy, process, or system improvements.
• Experience creating detailed reports and giving presentations.

Working Conditions and Physical Effort:

• Ability to work OT during peak periods.
• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical remote home office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees