Sr. Business Analyst (Program and Payment Integrity)

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Job description

Sr. Business Analyst (Program and Payment Integrity)

Requisition #: 433083
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Non-Clinical Professional
Work Shift: Day Shift
Work Week: Full Time
Weekend Work Required: No
Date Posted: Oct. 25, 2021

Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHC is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC has become a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, Johns Hopkins HealthCare is actually doing it. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for the members and communities we serve. If you are interested in improving how healthcare is delivered, join the JHHC team.

This can be a virtual work position depending on the State of residence. Must reside in one of the following to be considered: MD, VA, FL, PA, DE or District of Columbia.

POSITION SUMMARY:

The Sr. Business Analyst utilizes a variety of elicitation techniques to effectively gather pertinent information to plan, design, develop, and launch business, financial, and operations systems in support of core organizational functions. The BA must identify and create clear and concise alternative, constructive and forward thinking solutions for multiple business objectives and requirements. Recommended solutions will best fit the overall alignment with JHHC organizational goals. Solutions may include new applications, interfaces, architectures or process. Applications and interfaces will include but not be limited to claims payment systems, claim software editing systems, provider and member portals, authorization support systems such as Aerial, etc. Must be skilled in creating all supporting documentation and is able to create and utilize models and prototypes as required to solidify final requirements. Supporting documentation will include but not be limited to business design documentation, business requirements and functional specifications and configuration mapping requirements for inbound and outbound file solutions. Should be comfortable with both iterative/agile methodologies as well as traditional waterfall approaches to development. This individual will interact directly with source system vendors, understand downstream impacts, and will apply proven communication, analytical and problem-solving skills to create final functional definitions.

The Business Analyst will analyze and interpret Health Plan's product benefits, fee schedules, claims edits, provider agreements, and claims processing rules to assist with building algorithms for payment integrity library. The Business Analyst also works closely with the Data Scientists and Analytics team to provide business requirements necessary for algorithm development New ideations include Fee Reimbursement, Payment Policy, Benefit Configuration, COB, or Medical Policy rules used to ensure proper pre and post payments. The Analyst will research and stay abreast of all coding guidelines, industry-standard rules, and health plan claims operations to ensure the team is capturing all potential opportunities.

This individual should possess expertise in business rules that support various commercial and government programs of the organization. The incumbent with present and answer new concept development questions, and considerations to Medical Director, Claim Director and clinical leadership for input and feedback. This role will perform Quality Assurance of new algorithms to include peer review of newly developed algorithms, validation measures using claims systems and other data factors to ensure payment integrity, documentation of business assumptions and methodology as indicated and as needed. The Analyst will also review vendor concepts to reengineer and create internal concepts for implementation and/or process improvement. In addition, the Business Analyst will be responsible for managing projects and onboarding new vendors, identifying key components of a project and the impact across the organization and proposing the best solution. The analyst will also be responsible for coaching junior analysts and for preparing performance reports/metrics/dashboards for the department.

REQUIREMENTS:

Education:

• Bachelor's Degree in Business, HealthCare Management or related field preferred. Additional related work experience may substitute for some educational requirements. Master's Degree preferred.

Knowledge:

• Knowledge of a variety of elicitation techniques, including Core and ancillary systems implementation development lifecycles and how business analysts play a differing role in in each phase. Particularly knowledgeable about that role in the testing phase.
• Work requires extensive, strong familiarity with healthcare processes, systems, and terminology. Requires professional level of knowledge of healthcare information systems support. Work requires thorough knowledge and understanding of healthcare transactions such as claims, referrals, and eligibility inquiries. Strong knowledge of work-flow application software set-up and configuration is required. Demonstrates a strong knowledge of one or more business areas and develops functional requirements and recommends operation process flows to meet business requirements and objectives.
• Requires a comprehensive understanding of managed care operations including terminology and claims processing. Comprehensive understanding of reimbursement methodologies and acceptable billing practices. Extensive knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards. Previous experience in medical billing, claims auditing, claims analysis and actuarial analysis

Skills:

• Ability to ascertain the true needs that will address tactical and strategic goals. Ability to transfer information acquired from elicitation techniques into needed data and documentation. Expert facilitation skills required. Must possess efficient analytical skills with proven ability to recognize patterns and create solutions for change in process workflow or reallocation of resources. Ability to both lead teams and work within teams to meet goals.
• Strong verbal and written communication skills with demonstrated ability to research, problem solve and trouble shoot
• Proven ability to work independently while managing multiple tasks and priorities
• Functional understanding of health care claim data sets such as ICD-10, CPT and HCPC
• Previous experience within Payment Integrity ideation unit is preferred
• Ability to retrieve and analyze data using Microsoft Access, Excel and SQL
• Ability to retrieve and analyze complex data using Microsoft Access, Excel and SQL
• Strong knowledge of software implementation / development life cycle

Required Licensure, Certification, Etc.:

• Systems Business Analyst, Senior - A CPC Certified Professional Coder Certification is preferred but not required

Work Experience:

• 5+ years of business experience - managed care contracting, medical billing, claims auditing, claims analysis, and actuarial analysis.
• 5+ years investigating, researching, and analyzing claims data applying knowledge of medical or pharmacy policy to determine details of the overpayment
• 5+ years of experience working in Information Systems (software installation, system configuration, SQL/Oracle platforms)
• 5+ years MS SQL server experience including: SQL Server Analysis Services, SQL Server Reporting Services or SQL Server Integration Services

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.