Company :Highmark Inc.
Job Description :
The analyst is responsible for compiling and analyzing data relevant to the handling of all types of complex adjusted claims; conducting reviews of all organizational or functional activities related to fraud/abuse perpetrated by providers, subscribers, facilities, pharmacies, provider employees and/or employees of the company and ensuring Highmark compliance with all adjustment processes based on SOX remediation and Regulatory and legal guidelines. This job supports one or more analytical aspects of the application product life cycle, within a sub-product scope (one or more application components). Uses regular judgement and discretion to collaborate with customers in order to: Understand capability needs; Gather project specifications; Create business cases and cost sheet analysis; Translate high-level business needs into detailed requirements for new capabilities (and change request/enhancements on existing capabilities); Analyze data to determine business problems, trends, or opportunities for process improvements; Create/execute test cases; Provide root cause analysis and corrective action plans; Verify delivery of customer needs, and Ensure quality delivery. The incumbent identifies, documents, and resolves risks, defects and issues. Analyzes market trends for competitive insight to correlate into business value statements. Builds organizational and platform knowledge in one or more disciplines to advance professional track career. Uses functional and organizational knowledge to mentor junior resources. Requires thorough understanding of end systems impact of changes across multiple systems. The Analyst will identify potential areas of processing vulnerability through procedure review and report trending/analysis; generate reports for analysis and/or sampling; review audit samples for accuracy and appropriateness; act as the subject matter expert for all audit adjustment processes for workgroups, recommend and implement process changes, and coaching quality review staff. As a result of the analysis and sampling activity, the position will develop reports detailing the findings and trending results. The analyst will also be responsible to recommend any processing enhancements and/or internal control improvements.
- Work with customers, Software Engineers, Architects, Capability Managers, and other team members to capture capability needs and drive quality business solutions. Create and maintain deliverables such as business vision, requirements and personalization to different clients, and user interface design.
- Participate in the full software development life cycle by actively participating on Agile scrum teams in various roles, including, but not limited to, Scrum Master, Business Technical Analyst, User Interface designer, Capability Manager, or Tester, based upon experience and need.
- Support various aspects of requirements testing (e.g. testing plan, scenarios, documentation, defect management) to ensure minimal production defects are realized and completing analysis of the results tying back to customer impacts.
- Ensure compliance for required standards and all necessary approvals have been obtained throughout the project lifecycle.
- Effectively communicate with team members, customers, partners and management, including assisting with or conducting requirement walkthroughs and sprint reviews, reporting project status, enabling vendor solutions and providing accurate and concise documentation.
- Other duties as assigned.
- Bachelor's Degree in Business Administration, Business Management, Information Systems, or related field
- 6 years of related experience
- 3 - 5 years in IS/IT
- 1 - 3 years in Lean/Six Sigma experience
- 1 - 3 years in the Health Insurance Industry
- 1 - 3 years in the Healthcare industry
- Experience in claims and/or inquiry processing or equivalent experience in quality
- Experience with Microsoft Office Products
- Medicaid knowledge
- Experience with HealthTrio, HealthEdge/HRP, Altruista/Guiding Care
- Proficiency with reporting and analytical software tools (Alteryx, Tableau, SQL)
LICENSES OR CERTIFICATIONS
- Information Technology Infrastructure Library (ITIL)
- The Open Framework Group (TOGAF)
- Six Sigma
- Project Management Professional (PMP)
- Analytical Skills
- Communication Skills
- Report Writing
- Agile Methodolgy
- Agile Project Management
Language Requirements (other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )
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