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MCR Support Analyst

Company: Horizon Blue Cross Blue Shield of New Jersey
Location: Newark
Posted on: January 16, 2020

Job Description:

Job Summary:This full time, dedicated position is accountable for supporting MCR (Medical Cost Initiatives) through feasibility study, implementation and post-installation monitoring from a Service Division perspective. These projects include delegated vendor programs, Claims Xten and other correct coding initiatives, and Burgess and other out-of-network pricing methodologies and recovery opportunities.

This position is the analytical support to the Service Division MCR Initiatives Director to coordinate the successful implementation of Medical Cost Maximization projects and programs within the Service Division for the Enterprise owners.

RESPONSIBILITIES:

* Provides coordination of operations across the Service Division to ensure effectiveness and consistency in implementation of multiple and varied Medical Cost Maximization Programs

* Partners with HCM owners, IT and vendors to ensure success of the program

* Coordinates impact to the Service Division and assists with implementation tasks

* Ensures operational readiness including training, documentation, testing, staffing analyses, legal and compliance approvals, funding approvals, etc.

* Utilizes knowledge, experience, data inter- and intra-divisional relationships and tools to plan, forecast, recommend, seek funding for and oversee implementation of changes (including communication plans) within the Medical Cost Maximization, Delegated arrangements and Vendor oversight including, but not limited to

- Modification of claim edit rules and policies

- Integration of new or modified reimbursement policies

-Development of test beds, oversight of test output to ensure intent is reflected in claim payments

- Certification of annual compliance with settlement terms associated with codes and modifiers

- Root cause analysis and resolution

* Provides coordination of operations across the Service Division to ensure effectiveness and consistency in implementation of multiple and varied Medical Cost Maximization Programs

* Partners with HCM owners, IT and vendors to ensure success of the program

* Coordinates impact to the Service Division and assists with implementation tasks

* Ensures operational readiness including training, documentation, testing, staffing analyses, legal and compliance approvals, funding approvals, etc.

* Utilizes knowledge, experience, data inter- and intra-divisional relationships and tools to plan, forecast, recommend, seek funding for and oversee implementation of changes (including communication plans) within the Medical Cost Maximization, Delegated arrangements and Vendor oversight including, but not limited to:

- Modification of claim edit rules and policies
- Integration of new or modified reimbursement policies
- Development of test beds, oversight of test output to ensure intent is reflected in claim payments
- Certification of annual compliance with settlement terms associated with codes and modifiers
- Root cause analysis and resolution

* Assists in the implementation of strategies and initiatives to minimize out-of-network cost exposure.

* Coordinates with HCM operational issues and impacts for contracted vendors brought on board to resource various areas of Medical Cost Maximization including, but not limited to:

- Out of network utilization
- Provider outlier audits, identification and oversight of remediation plans
- Delivery of enhanced Code Edit logic for all LOBs and products
- Delegated arrangements

* Provides oversight of operations that validates and oversees necessary corrective action plans to address and ensure compliance with regulatory and settlement terms

* Collaborates with the business groups to develop, document and standardize procedures and workflows to support operational improvement

* Help coordinate development of test plans and facilitate participation in testing activities. Coordinate and manage development of system acceptance criteria

* Leverage existing technology by identifying opportunities to automate manual processes and interventions; identify opportunities to incorporate new technology into processes and flows

* Work across departments/divisions to achieve business goals; leverage key internal and external relationships to access the information, products and resources (technology, training, staff, etc.) necessary to successfully support MCR projects.

* Performs other duties as assigned

Compliance Statement:
Demonstrates knowledge and understanding of the laws, regulations and policies that pertain to the organizational unit's business and conforms to these laws, regulations and policies in ...

EDUCATION/EXPERIENCE:

* Bachelors degree required. In lieu of degree, 4 years of additional experience is required.

* Project management experience or participation as a key Subject matter Expert (SME) is a plus

* Requires broad-based experience with a minimum of 5 years in managed healthcare or related industry

* Successful track record in managing operations with process improvement background desired

* Claims systems knowledge is preferred.

* Past experience on system implementations in a fast-paced, high pressure environment is preferred

* Experience with specialty health plan products and vendors helpful

KNOWLEDGE:

* Requires broad understanding of claims systems and related ancillary systems used in the Service Division

* Requires business and/or technical expertise from previous claims projects and work flow changes and impacts

* Requires knowledge of the deep understanding of the QBLUE and/or NASCO system

* Requires knowledge of project management life cycles and related tools and practices

* Must have a solid understanding of claim processing including pricing and code editing

* Must have strong organizational and analytical skills and demonstrated ability to effectively manage multiple projects at one time

* Must have strong inter-personal skills with a demonstrated ability to lead cross-divisional work teams

* Must demonstrate an understanding of the interdependences between the business, clinical and financial side of the health care business

* Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project) and Lotus Notes; Should be knowledgeable in the use of intranet and internet applications:

* Must have a working knowledge of the impacts of mandates and legislation on overall claims processing and contracting

SKILLS AND ABILITIES:

* Requires technical proficiency in Horizon claims operating models

* Requires excellent coordination management and organizational skills

* Requires strong analytical and problem solving skills

* Require excellent conflict management and relationship management skills

* Requires excellent facilitation, coaching and platform skills

* Requires strong project management skills based on Horizon project management practices

* Requires ability to work on a matrix-managed project team

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Keywords: Horizon Blue Cross Blue Shield of New Jersey, Newark , MCR Support Analyst, Professions , Newark, New Jersey

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