Sr. Pay Integrity Analyst

Company Description

Why Wellmark: We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we've built our reputation on over 80 years' worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors-our members. If you're passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today!

Learn more about our unique benefit offerings here.

You can also learn more about working at Wellmark here.

Job Description

Provides payment integrity insight and deep experience in determining the viability of a new idea or concept as well as reviewing results in current value streams. Plays a critical role in reviewing business requirements for payment integrity system solutions and will use vast technical knowledge for business and technical requirements as well as testing all phases of business system solutions related to payment integrity.

Qualifications

Required:

• Associate degree or direct and applicable work experience.

• Minimum 4+ years of related experience which includes healthcare, healthcare operations, or health insurance, payment integrity value streams - preferably with PrePay experience.

• Facets system knowledge and/or experience as well as experience combining technical expertise with knowledge of operational business processes demonstrated through elicitation, translation or documentation of business requirements, system testing, etc.

• Demonstrated familiarity with APR-DRGs and/or EAPG groupers, claims pricing/ payments, etc.

• Exhibits strong skills in investigating, researching, and analyzing claims data applying knowledge of medical or pharmacy policy to determine aberrant billing activity.

• Strong communications skills (verbal/written) with the ability to articulate complex information or solutions to internal and external stakeholders, including vendors.

• Demonstrated critical thinking, problem solving/troubleshooting and continuous process improvement skills.

• Ability to analyze and assess business requirements for new or existing system capabilities and contribute to the design and structure of system parameters.

• Workflow management skills, including an understanding of sequential progression of tasks or processes and their respective impacts.

• MS Suite and Business Objects proficient.

• Self-starter with strong time management, organization skills, and the ability to effectively prioritize projects or tasks.

• Ability to coach and mentor others through guidance or feedback.

Preferred:

• Advanced level of proficiency with MS Excel

Additional Information

a. Analyze how new payment integrity ideas or concepts will impact business and claim operations in a way that is abstracted from how business functions are implemented by technology or how they manifest in processes today.

b. Provide thought leadership in the review and vetting of new ideas and concepts within a team dedicated to transformational change.

c. Use claim's operations organization knowledge to, which provides operational insight and allows a broad perspective of the big picture.

d. Evaluate opportunities to integrate new ideas, concepts, technologies, data, processes, and business models into existing organizational capabilities.

e. Evaluate new ideas or concepts and recommending strategic and tactical options - including consideration of similar capabilities across the enterprise, implementation challenges, and business priorities.

f. Collaborate and act as liaison among stakeholders to understand structures, policies, and operations primarily of the Payment Integrity Office but also other divisions of Wellmark.

g. Review and scrutinize all business requirements for payment integrity related system solutions; monitors and maintains the integrity of the system infrastructure and acts as the subject matter expert (SME) for business and technical requirements.

h. Test all phases of payment integrity related business system solutions. Coordinate and facilitate strong internal partnerships with internal and external stakeholders to ensure timing of all technical deliverables/projects (e.g. modifications, interfaces, upgrades, conversions, etc.).

i. Interact and partner with project/program managers to ensure active participation; clarify understanding of high level business needs and requirements on complex projects.

j. Lend subject matter expertise to department, division, and organization matrix partners, as needed, to assist with pricing and reimbursement matters.

k. Other duties as assigned.

An Equal Opportunity Employer

The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law.

Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at careers@wellmark.com

Please inform us if you meet the definition of a "Covered DoD official".