POSITION SUMMARY:

The Claim Dispute & Strategy Analyst is responsible for researching state and payor IDR protocols and analyzing eligible claims that receive under payment or non-payment. This position oversees the billing vendor and process of dispute resolution claim submission and payment requests with payors and third-party dispute resolution entities.

PRIMARY RESPONSIBILITIES:

• Formulates and develops presentations for project analysis needs from Finance, Billing, Market Access, Product Leads, and other teams as required.
• Identify functions and barriers that affect ASP and revenue including identifying trends, opportunities, and risks for all payors and products.
• Research complex benefits and insurance verification using various systems and portals internal and external.
• Investigate designated payors' literature and agencies, and stay current on new indicators, such as state statutes, laws, and other requirements.
• Develops strategies to improve reimbursement and reduce denials for assigned payors based on trends and analysis findings.
• Identifies areas of opportunities for process improvements, automation, and efficiencies.
• Creates management reports and custom dashboards & visualizations.
• Initiates and supports projects, initiatives, solutions, and other change management
• Conducts complex trend review, forecasting, sensitivity analysis, what-if scenarios, and other analyses.
• Partner with multiple internal cross-functional teams and successfully manage multiple product projects simultaneously.
• Presents information, analysis, updates, financial risks, and recommendations to a specific audience.
• Performs analysis of operational, production, financial, and other data.
• Analyzes payor behaviors, systems, and processes in reimbursement to optimize performance.
• Ensure data integrity and control over business processes by developing data management best practices.
• Operationalize business intelligence solutions to highlight strengths and opportunities to meet organizational strategies, objectives, and goals.
• Analyze large data sets of structured, semi-structured unstructured data to discover data insights and collaborate with business partners to deliver business value.
• Participates in weekly meetings to review key metrics, workflows, trends, payor performance improvement opportunities, and strategies.
• This role works with PHI regularly both in paper and electronic form and has access to various technologies to access PHI (paper and electronic) to perform the job.

QUALIFICATIONS:

• Bachelor's Degree healthcare-related field of study or equivalent experience.
• Minimum of 5 years of experience in claim analysis, dispute resolution, or appeals and denials experience.
• Management, Supervisor, or Project management experience preferred.
• Knowledge of CPT/HCPCS. ICD-10, modifier selection, and UB revenue codes.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Proficiency with medical or claim billing systems, Microsoft Excel, reporting software, and basic procedure coding knowledge.
• Knowledge of medical terminology and abbreviations, and health care nomenclature and systems.
• Strong communication (verbal and written), organizational, problem-solving solving, and team player skills.
• Knowledge of appeal and independent dispute resolution regulations.
• Ability to navigate across multiple customer demands and balance competing priorities successfully.
• Ability to analyze, identify, and articulate identified trends and report trends succinctly clearly, and concisely.
• Ability to independently solve complex problems using critical thinking skills.
• Maintains confidentiality of sensitive information.
• Analytical skills required.
• Ability to think critically and identify the global impact across the revenue cycle with a solution-oriented approach.
• Ability to develop, implement, and produce complex analysis and reports.

PHYSICAL DEMANDS & WORK ENVIRONMENT:

• Duties are typically performed in a remote office setting.
• This position requires the ability to use a computer keyboard, communicate over the telephone and read printed material.