Claims Analyst Remote Denver, CO

Job Id: 56978 Title: Claims Analyst Location: Remote, Denver, Colorado Duration: 12 Months Description:

• Develop a deep understanding of the organization, its strategy, constraints, and goals in order to facilitate discussions and generate effective solutions to the problems and projects at hand.
• Must have, or quickly develop, with little guidance or support, a detailed understanding of all current BHA data systems and those with which the BHA interacts.
  • Encounter Claims System (Encounters)
  • Colorado Client Assessment Record (CCAR)
  • Drug and Alcohol Coordinated Data System (DACODS)
  • HCPF Medicaid Management Information system (MMIS)
  • Behavioral Health Provider EHR vendors Netsmart, Streamline, Qualifacts, Cerner, and others.
  • Colorado Health Information Exchanges CORHIO and QHN.
  • And behavioral health provider networks:
    • Colorado Community Managed Care Network (CCMCN)
    • Colorado Behavioral Healthcare Council (CBHC)
    • Managed Service Organizations (MSO)
    • Administrative Service Organizations (ASO)
    • Regional Accountability Entities (RAE)
    • Colorado Crisis Services

• Participate as a key member of the Product Delivery Team.
• Subject Matter Expert on both Medicaid and non-Medicaid behavioral health (mental health and substance use) data related to:
  • 837 file formats (specifically 5010P)
  • API, batch, XML, 837 data submission processes.
  • Uniform Coding Standards (CPT/HCPCS/Revenue Codes)
  • American Society of Addiction Medicine (ASAM) dimension determination
  • Claims/Encounter processing
  • Rate setting
  • Contract compliance
  • Mental health and substance use data collection and submission standards, as well as best practices
  • Payment model integration
  • PHI, HIPAA, 42 CFR Part II data security, privacy regulations and consent management
• Gives guidance to BHA leadership and stakeholders within the behavioral health community, as well as to other state agencies as it relates to areas of expertise in data, service coding, financial and compliance issues.
• Expertise at estimating business analysis work efforts and deadlines on complex IT projects.
• Ability to creatively and collaboratively work with disparate groups each with their own, and potentially differing, interests and priorities.
• Facilitate collaborative workshops that involve those impacted by a project and other stakeholders to understand business process, workflows and current pain points. This includes a comprehensive understanding of the goal of each new project, and all systematic changes that must be made in order to successfully complete each project.
• Works closely with the Financial Team to identify and document financial and contractual reporting needs. Includes business rules, workflows and gaps based on observation of, and exploration into, payment models and recommendations, contract reporting requirements, service coverage, daily operations and communications with this team.
• Works closely with the Data & Evaluation Team to identify and document data required for financial, contractual, utilization, block grant, and various annual reporting, as well as having the ability to respond to governor, legislative, media, CORA and other miscellaneous requests. Includes business rules, workflows and gaps based on observation of, and exploration into, daily operations and communications with this team.
• Identifies and documents specialized reporting and dashboards needed in order for the Data & Evaluation team to publish utilization and various other public-facing information and data.
• Communicate scenarios drawn from interactions with other stakeholders that illustrate the needs of various groups that will be interacting with data from the MMIS system. These may be used to design various enhancements and added features to the legacy and/or new data systems and identify gaps in MMIS data and reporting capabilities.
• Work closely with the Product Owner and Portfolio Manager to translate business requirements into user stories for development and testing activities.
• Support the Product Owner in maintaining and prioritizing the product backlog according to business value and alignment with strategy.
• Identifies and documents required analytical tools, data and utilization reports that will monitor organizational progress against health outcomes measures and contract compliance.
• Creates detailed business requirements that are passed on to the Quality Assurance Team, Data Analysts, OIT, HCPF, contractors, and/or software vendors for design, development, testing and implementation.
• Create and maintain a business requirement documentation library for all new data systems and enhancements to legacy systems.

• Support the BHA in growing their capacity for business analysis and requirements gathering by demonstrating value, achieving buy-in from all stakeholders while integrating best practices strategically throughout the organization.
• Mentor and coach junior members of the team who are taking on new tasks and roles within business analysis and requirements gathering.

• Additional, relevant, paid or unpaid experience can substitute for the required education on a year-for-year basis.

• Experience with MMIS, Medicaid specific to Rate setting, billing and claims and Financial Business Analysis
• Experience in Agile and/or Health IT environment
• At least five years of experience applying BA methodology in complex environments.
• At least three years of experience leading organizations through business analysis and requirements gathering across organizational silos.
• Experience working collaboratively with cross-functional teams across the product delivery lifecycle using modern software development practices such as agile or lean.
• Basic understanding of reporting abilities of linking data systems with Tableau.

• Expertise in technical writing and construction of protocols and requirement documentation.
• Excellent interpersonal, verbal, and written communication and public speaking skills.
• Self-motivated and able to effectively manage time and tasks.
• Ability to solve complex problems, participate in continuous improvement, and adapt to the ideas of others.

• Ability to work effectively with key stakeholders, speak and write authoritatively and compellingly, resolve communication problems, and negotiate and manage competing interests.
• Ability to work well with stakeholders regardless of position and authority, contribute to workgroups and committees, and adhere to clear lines of responsibility and accountability.