Configures medical and pharmacy benefit packages, premium billing, finance, eligibility and customer service sub-system reference files using the managed care software provided by Epic. Designs, develops and maintains uniform and customized benefit packages for all insurance products, including HMO, PPO, POS, HSA, EPO, Medicaid and Medicare Supplement. Assists in operational planning to ensure interdepartmental accuracy of benefit interpretation and claims payment. Serves as project leader during system upgrades and implementation of new functionality. Serves as user support for the various business areas using the software, including enrollment, finance, claims, customer service, provider & fee schedule maintenance and marketing. Process jobs and reports related to Electronic Data Interchange (EDI) transactions. Perform technical system functions related to the transfer and retrieval of data files using standard IT protocols, such as FTP. This position may require occasional weekend work and flexible hours to meet project deadlines. Performs other duties as assigned.
Responsibilities
Essential Duties and Responsibilities
* Develop and maintain expert level knowledge of Epic software, including claims, authorization, customer service, enrollment, provider reimbursement, finance and EDI modules, as well as detailed knowledge of workflow processes.
* Business analyst suggests ways to maximize software applications to assist with process improvements and workflow changes.
* Business analyst works on problems ranging from moderate to complex, in which analysis of the situation or data requires a detailed review of factors and issues, and coordination of efforts between programmers, vendors, system administrators and users.
* Build and maintain benefit package configuration within Epic
* Coordinate the loading of software fixes and upgrades, and perform tests to ensure seamless implementation of new functionality.
* Create and maintain documentation to track testing and changes to software.
* Coordinate user system security requests for all applications and systems used by MercyCare employees, and set up user security according to the most current security policy.
* Import EDI claims and other transactions from various sender locations, and run jobs to process files into the appropriate module, on a daily basis.
* Export EDI remittance advice files to appropriate provider trading partners. Configure and transmit EOB and EOP electronic files to vendor for mailing, using standard transmission protocols.
* Develop and maintain expert knowledge of third party software and obtain required Epic certification(s)
* Work with users to ensure Standard Operating Procedures (SOPs) accurately reflect system functionality and optimization.
Culture of Excellence Behavior Expectations
To perform the job successfully, an individual should demonstrate the following behavior expectations:
Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.
Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.
Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.
Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.
Education and Experience
Bachelor's degree from four-year college or university, with 3-5 years in insurance claims operations experience.
In lieu of degree 8-10 years minimum of insurance claims and information systems experience equivalent will be considered.
Knowledge of hospital & professional provider billing and claim coding methodologies.
Proficient in use of Microsoft Office products.
Certification and Licensure
Epic Certification
Skills and Abilities
Assignments are based on abilities and are normally received in the form of results expected and due dates. Only general procedures are available to guide work. Able to work with minimal supervision.
Requires excellent verbal and written communication skills and ability to coordinate and prioritize tasks and project components.
Requires excellent teaching, presentation and organizational skills.
Special Physical Demands
The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.
While performing the duties of this job, the employee is regularly required to use hands to finger, handle and feel; reach with hands and arms, and talk and hear. The employee is frequently required to sit. The employee is occasionally required to stand, walk, climb or balance and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Level of Supervision
This job has no supervisory responsibilities.
Supervises
N/A