Business Analyst – Operations Performance

Summary
The Business Analyst – Operations Performance serves on projects of moderate to significant complexity. Interacts with internal and external customers to identify needs and determine solutions that deliver maximum value. Maintains a strict adherence to departmental standards related to documentation and artifacts and provides peer review for the work of other business analysts.


 
Duties

• Demonstrated ability to analyze problems, probe facts, identify and question assumptions and find creative and effective solutions to meet business goals without compromising customer satisfaction.
• Collect, organize, and analyze information within vendor systems and reports.
• Collaborate with vendor partners to ensure seamless alignment of business processes with the vendor system.
• Evaluate the effectiveness of integration efforts and support continuous improvement initiatives.
• Develop and deliver reports and presentations to stakeholders, including senior management to drive informed decision-making and ensure transparency in efforts.
• Foster a work environment of continuous improvement Collaborate with internal stakeholders to include senior management to ensure comprehensive and efficient resolution of issues and development of process improvement.
• Maintains knowledge of GEHA’s policies, procedures, and contract provisions.
• Participate in working sessions with cross functional teams to ensure requirements are clearly defined and provide clear expectations for success.
• Comprehensively review and evaluate second level appeals. Determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
• Provide written acknowledgment of member for second level appeals.
• Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
• Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, policies and procedures, best practices, and performance issues.
• Prepare written responses to OPM for second level appeals that appropriately address each complainant’s issues and are structurally accurate.
• Plans, schedules, and facilitates meetings.
• Develops, tracks, monitors, and communicates project progress against the project plan.
• Coordinates the input, process, support, and communication with all functional areas that impact or are impacted by project scope, business value, risk, and resource requirements.
• Ensures integration of the project activities to meet schedule, deliverables, and manages process changes to achieve customer requirements.
• NSA/IDR review and reporting
• Audits claims, reports or electronic files for accuracy, benefit payment, and compliance with policies and procedures
• Prepares and presents quality audit reports for management to identify trends, issues, and performance.
• Manage the yearly ID card file.
• Complete yearly 1095B and 1099 process.
• Complete audit reviews of QA work/output from UMR to include, but not limited to: Calls, claims, eligibility & enrollment, appeals, payment integrity and Provider data management.
• Calibrate with QA team at UMR to ensure results are in alignment; escalate when outcomes cannot be aligned.
• Complete audit reviews
• Actively engage and demonstrate characteristics of a collaborative team member.

• Associates degree in a related field.
• Additional years of qualifying work experience may be considered in lieu of formal education.

• Requires three (3) years of progressively responsible heath plan experience.
• Experience creating collaborative and productive relationships with internal and/or external partners.
• Requires highly effective verbal and written communication skills and good organizational skills.
• Requires knowledge of medical terminology, medical codes, and related reference materials.
• Excellent problem solving, organizational, and analytical abilities.
• Experience with Microsoft Excel