Claims Systems Lead Analyst
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Job Description
Claims Systems Lead Analyst managing EviCore claims implementations, configuration, testing, and data integrity. Supporting Evernorth’s healthcare and benefits solutions through SQL, Access, and client collaboration.
Responsibilities:
- Manage complex Claims Systems projects and implementations within the claims adjudication engine
- Ensure data integrity, data security, and process optimization for EviCore Claims processing
- Document and develop application functionality and data configuration
- Work from Azure DevOps using project methodologies to maintain and update tickets for Claims System projects and requests
- Mentor the Senior Analyst on complex enhancement and configuration designs
- Provide Claims Systems subject matter expertise to internal departments, including Claims Configuration, Client Engagement, Program Leads, Claims IT Development, and QA
- Lead external client calls and support clients in all aspects of the Claims System application
- Define business, technical, and claims data exchange requirements
- Instruct on data file mapping for providers, members, authorizations, claims, and related data
- Create test/use cases, perform SI testing, and support UA testing for client implementations and internal integration/migration efforts
- Create simple to complex SQL queries to review Claims System configuration and claims data
- Update configuration through Access Database
- Conduct postproduction claims reviews to validate production changes
- Investigate claim processing and perform Claims Configuration root cause analysis
- Collaborate and communicate with internal and external business operations, IT, and QA departments
- Assist reporting development, RFP data processing requests, training, maintenance transition, and process/product workflow documentation
- Perform duties under self-direction and make decisions as necessary
Requirements:
- Bachelor Degree in a computer related field preferred or equivalent work experience
- 5+ years of claims and health care experience required
- 5+ years of experience in medical Claims Systems Configuration preferred
- Experience running complex queries utilizing Microsoft SQL
- Proficient in Microsoft Access Database, including queries and data manipulation
- Proficient in Microsoft Excel, including pivot tables, charts and formulas
- Strong technical competence, proven critical thinking, and impeccable communication skills
- Accomplished in claims lifecycle knowledge and claims adjudication framework
- Knowledge of industry standard claims data types and editing rules, including ICD, CPT/HCPC, Rev Codes, and NCCI
- Familiarity with database management systems, including DB2 and SQL Server
- External client-facing experience preferred
- Experience creating test plans/use cases and SDLC models
- Ability to obtain home internet through cable broadband or fiber optic service with at least 10Mbps download/5Mbps upload
Benefits:
- Remote work arrangement
- Internet connection through a cable broadband or fiber optic internet service provider with minimum speeds of 10Mbps download/5Mbps upload when working from home
- Equal employment opportunity protections
- Reasonable accommodation support for the online application process
- Tobacco/nicotine cessation program eligibility in applicable states
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