Job description

What You’ll Be Doing:

• Define business requirements and acceptance criteria/test cases Define business requirements and acceptance criteria/test cases related to State Medicaid and CMS programs
• Review regulations from State Medicaid and CMS programs. Utilize a variety of software and platforms for statistical analysis and research concerning data Create and standardize solutions and workflows.
• Perform business analysis of identified process and software gaps or inefficiencies and develop plans to fill those gaps for internal business processes and for external clients.
• Perform requirements review with external and internal stakeholders and obtain sign off from all required individuals.
• Identifies and documents system deficiencies and recommends solutions.
• Integration Quality team while executing the test cases/script

The Experience You’ll Need (Required):

• Extensive knowledge in health insurance third party administrator concepts for commercial, federal and state government plans specifically support operational processes for provider data management functions, enrollment and eligibility, member benefits, claims adjudication and EDI Interfaces functions.
• Knowledge of State regulations to determine provider meets qualification to be enrolled.
• Knowledge of provider files from State Medicaid programs to decipher provider enrollment and eligibility rules.
• Knowledge of provider type designation identified by the State Medicaid programs. Knowledge of provider and member portal functions.
• Knowledge of provider reimbursement methodologies about Commercial, CMS and State defined guidelines.
• Knowledge of provider matching criteria for claims. Knowledge of Coordination of Benefits (COB) and Claim Authorizations functions.
• Knowledge of Setting up communications for EDI transmissions using FTP, SFTP and real time API setups.
• Knowledge of health insurance, HMO and managed care principles including Medicaid and Medicare regulation.
• Solid analytical skills with the ability to compile data from many sources and define designs for enrollment to benefit plan configuration.
• Research, interpret and summarize new state, federal and client rules regarding department functions.
• Alter or create policies and procedures to adhere to those rules. Solid communication skills with working session facilitation.
• Strong time management, attention to detail, analytic and organizational skills. Excellent interpersonal, oral and written communication skills.
• Able to work independently and within a collaborative team environment with little guidance/supervision.

Finishing Touches (Preferred):

• Associate or bachelor’s degree preferred.
• HMO/PPO Claims, Medicaid, Medicare and/or managed care environment preferred.
• Certified Business Analyst is strongly preferred; equivalent demonstrated business analysis experience.
• Extensive experience with the System Design Life Cycle (SDLC).
• Superior root cause analysis skills, including corrective action planning and ability to provide documentation to support analysis.

Job Type: Full-time

Salary: $80,000.00 - $95,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Bonus pay
• Commission pay

Experience:

• Medicaid: 5 years (Required)
• Health Insurance: 5 years (Preferred)

Work Location: Remote

www.arclintfl.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, www.arclintfl.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, www.arclintfl.com is the ideal place to find your next job.