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Denver Health Business Analyst - Payment Integrity, Managed Care Administr in Denver, Colorado

Business Analyst - Payment Integrity, Managed Care Administration (JobID: 3638)Job SummaryUnder minimal supervision supports the continuous evaluation of the Departmentin alignment with Denver Health's financial, strategic, and operationalinitiatives and projects. Evaluates business processes, anticipatesopportunities and challenges, identifies areas for improvement and makesdata-driven recommendations. Coordinates and performs duties related to dataacquisition and analysis for multiple projects simultaneously.Conduct complex, in-depth analyses of claim payments and theirmethodology, identifying trends and patterns to ascertain costavoidance/overpayment recovery opportunities. Apply root cause analysis todesign and develop solutions to payment integrity opportunities/issues,and coordinate implementation efforts with internal stakeholders, as well asvendor(s) and providers as applicable. Ensure medical claims, records,and other documentation essential to claims submission and reimbursement arein compliance with state and federal guidelines, provider contracts,Denver Heath Medical Plan (DHMP) policy, national coding guidelines,and industry standards. Detect areas of billing inefficiencies, internalcontrol weaknesses, and noncompliance and provide recommendations forcorrectivResponsibilities1.Conduct thorough analyses of all medical claims for adherence to state andfederal guidelines, provider contracts, DHMP policy, national codingguidelines, and industry standards.2.Review, research, and interpret medical record documentation, claimsdata, contractual guidelines, payment methodologies, and systemadjudication to identify trends and patterns in complex claims payment datathat result in recovery opportunities.3.Create new, recurring and ad hoc reports to identify costavoidance/overpayment opportunities using large data sets on multiplevariables. Provide data, analyses, and recommendations to management onall findings affecting payments, including policy, contract issues,provider errors, pricing, and systems and claim processes.4.Work with internal stakeholders to make any necessary technical updates tothe system, policies, and procedures when necessary, as well ascoordination of education to providers. Track and report progress ofprospective and retrospective cost avoidance/overpayment recoveries.5.Carry out new recovery concepts within the established deadlines with a highlevel of accuracy. Resolve any challenges made to the proposed costavoidance/overpayment concepts throughout the organization, including,but not limited to, Provider Relations, Provider Contracting,Medical/Payment Policy and Legal.6.Build strong stakeholder relationships and deliver solutions that meetstakeholders' expectations. Establish and maintain effectiverelationships, both internal and external.7.Introduce best practices around post-payment recoveries.8.Provide ongoing feedback to key internal stakeholders with the goal ofimproving internal payment control and reducing paymentinconsistencies/overpayments.9.Perform audit peer review analysis periodically to ensure quality of resultsand consistency in content, analytics, and adherence to departmentpolicies and procedures.10.Develop written reports in accordance with reporting standards. Ensure thatall audit findings, exceptions, and proposed adjustments to workpapers/communication documents are well defined and explained or included inreports.11.Manage appeals process with providers and third-party arbitrators whennecessary.12.Mentor less experienced staff.13.Lead department projects and initiatives.14.Other duties as assigned.Experience1.Two (2) years in data analysis, process improvement, or projectmanagement required.Knowledge, Skills and Abilities1.Must be able to work independently and meet schedules and deadlines. Abilityto handle multiple tasks, simultaneously.2.Exceptional ability to gather, understand, and utilize data to informdecisions and make recommendations. Excellent communication skills and