Senior claims analyst job description

For a 4th year in a row, Aspirus has been recognized as one of the top 15 Top Health Systems in the United States by IBM Watson in their annual study identifying the top-performing health systems in the country based on overall organizational promotes a professional and pleasant atmosphere for clients and staff through excellent and effective communication.
We are seeking a Senior Claims Analyst in Wausau, Wisconsin. The Sr. Claims Analyst works with operations and provider relations/contracting departments analyzing claims activity to identify and quantify claim adjudication errors, identify claims trends to identify opportunities for improvement, assist in provider contract negotiations, and review contract pricing setup in the claims system.

PRINCIPAL DUTIES AND RESPONSIBILITIES :

Prepares financial analyses of claims processing activity to identify and quantity claim adjudication errors. Works with provider representatives to report and resolve payment discrepancies. Completes regular reviews of claim processing activity to ensure claims are paid consistent with provider contracts. Prepares analysis of provider discounts to identify opportunities for improved contract terms and network configuration. Completes claims reviews to track and/or identify claims trends such as out-of-network utilization, claims denials, and pending claims. Assist in the preparation for contract negotiations and completes analysis on the impact of proposed contract changes. Participates in provider meetings regarding contract and/or claims processing concerns. Reviews provider reimbursement questions and if necessary, assists in determining appropriate actions to resolve payment issues.


MINIMUM KNOWLEDGE, SKILLS AND ABILITIES
:

Education

Bachelor's degree in healthcare, health insurance, finance, or related field preferred.

Experience

Minimum of three years' experience in health insurance claims analysis or related experience.

Annual Competencies

Annual competencies as required by Aspirus and/or various regulatory agencies based on entity and/or job position.

**This is a hybrid position and offers the opportunity to work 50% of time remotely and 50% of time in the office.

Work with CM Group Claim leadership to identify, develop, adapt, and monitor key insights through data analysis and drive those insights into action with applicable business teams. Serve as a liaison between business partners, IT and Business Intelligence to provide technical solutions to meet end user needs and maintain established business relationships. Develop and recommend key performance indicators to help drive decisions based upon data and directly influence data metrics, reporting roadmaps, dashboards, and executive report development.
Responsibilities
• Partner with business teams to consult, define, build, and implement the right set of performance metrics, reports, and dashboards to effectively manage the business unit.
• Distill and interpret data in spreadsheets and workbooks to identify trends, research anomalies, and make recommendations and corrections as needed.
• Contribute to strategic planning processes and recommend process improvement initiatives, influencing the direction of the claim organization.
• Support data needs related to business cadence such as weekly, monthly, and quarterly business reviews.
• Enable effective decision making by retrieving and aggregating data from multiple sources and compiling it into a digestible and actionable format.
• Conduct ad-hoc analysis projects across multiple systems, answering complex business questions, and providing actionable insights to the leadership team to inform decisions and strategy.
• Partner and collaborate with other Business Analysts on best practices, prioritizations, data management, and reporting roadmaps.
Qualifications
• Bachelor's degree in business, engineering, statistics, computer science, data management, mathematics, or related field is preferred. May consider equivalent experience in lieu of a degree.
• Minimum of five years of experience in a business analyst, data analyst, or statistical analyst role.
• Prior experience writing and optimizing SQL to handle extremely large datasets is required.
• Demonstrate understanding of data warehousing and data modelling.
• Direct experience with multiple data visualization tools, including Cognos, S.A.S, and Power BI is required.
• Experience building business forecasting models is desired.
• Proven problem-solving skills, project management skills, attention to detail, ability to influence others, and exception organizational skills.
• Demonstrate self-motivation and drive to remain focused on goals and objectives to improve overall business performance and outcomes.
• Excellent verbal and written communication and interpersonal skills.
• Ability to effectively communicate with both business and technical teams.
• Ability to work collaboratively with non-technical customers and team members and translate business questions into analytical requirements.
Church Mutual Insurance Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
#li-hybrid
We can recommend jobs specifically for you! Click here to get started.

Hybrid position in Northbrook, IL 2 days weekly.As a Rebate Claims Sr. Analyst, you will play a key role in the successful invoicing of drug manufacturer rebates. The Trade Rebate Claims team manages and tracks the prescription claim volume that flows into the CVS Rebate system. You will work as a team member completing monthly claim validation procedures and analyses to prepare claims for rebate invoicing to drug manufacturers. You will also work closely with internal business partners to share information and data analyses that will ensure the timely validation and finalization of claims to be invoiced. This role may require working occasional evenings or weekends. As a Rebate Claims Analyst, your responsibilities will include:• Creating and running SQL queries to identify claim anomalies and perform ad hoc analysis• Performing monthly claims validation procedures in preparation for rebate invoicing to drug manufacturers • Researching plan designs in the adjudication system• Verifying client plan design tiers and reviewing and analyzing formulary assignments• Working within the rebate claim system to update claim information • Working with implementation and account teams to on-board new Rebate Only clients in the rebate system
Pay Range

The typical pay range for this role is:

Minimum: 43,700

Maximum: 97,400

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

• 2+ years of professional experience, preferably in PBM, Claims, or a related field• 1+ years of experience writing SQL queries and managing data in a professional or academic setting

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications

• Strong Excel skills• Strong organizational skills and the ability to manage multiple projects and priorities• Strong written and oral communication skills• Experience working in a fast-paced team environment, using problem solving and analytical skills to meet critical deadlines• Knowledge of pharmaceutical products/pharmaceutical industry• Experience working in RxClaim

Education

Bachelor's degree required. Equivalent work experience may substituted.

Business Overview

Bring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.