Business Analyst Sr, Claims, Covered California

CalOptima is a mission-driven, community-based healthcare organization serving members with excellence and dignity. The Senior Business Analyst will support Claims Administration by translating business needs into analytical and reporting solutions, analyzing claims issues, coordinating user acceptance testing, supporting regulatory compliance, and providing training and subject matter expertise for Covered California and other lines of business.

Responsibilities:

• 90% - Business Support
• • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability
• • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department
• • Provides guidance and supports department staff with escalated issues and inquiries related to Covered California benefits, regulations and claims processing requirements
• • Leads and manages multiple concurrent projects and workflows to ensure timely and accurate completion, including projects that impact Covered California claims, system configuration or regulatory alignment
• • Analyzes APLs, MedLearn notices and Medi-Cal monthly bulletins to identify potential impact on the department
• • Implements benefits or process changes that impact system configuration due to federal and state notices
• • Supports departmental compliance with applicable state and federal regulatory requirements, including analyzing guidance, implementing required operational changes and ensuring alignment across claims processes and system configuration
• • Identifies training needs and assists in developing desktop procedures and policies for lines of business affected by system or regulatory changes, including updates that directly impact Covered California processes
• • Participates in cross departmental workgroups and discussions related to program implementation, including initiatives tied to Covered California and system or regulatory changes that affect claims
• • Serves as the department's SME for all lines of business, leading advanced claims analyses, case research and documentation, while conducting system testing to ensure regulatory, coding, contract and configuration updates perform as intended and are accurately documented
• • Trains staff regarding system enhancements or changes, including updates driven by Covered California requirements, deficiencies identified from claims look-back analysis and User Acceptance Testing (UAT) findings
• • Provides analytical support and technical expertise to executives, directors and staff by delivering insights on Covered California performance, trends and compliance, while partnering with department leadership and internal teams to identify and implement process improvements that enhance efficiency and compliance in claims operations
• 10% - Other
• • Completes other projects and duties as assigned

Requirements:

• Bachelor's degree in business administration, health care administration, health services or related field PLUS 3 years of experience in claims, managed care benefits and operational protocol in the health care industry required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying
• 3 years of experience in Medi-Cal managed care or Medicare Advantage required
• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds
• Work independently and exercise sound judgment
• Communicate clearly and concisely, both orally and in writing
• Organize, be analytical, problem-solve and possess project management skills
• Work in a fast-paced environment and in an efficient manner
• Manage multiple projects and identify opportunities for internal and external collaboration
• Motivate and lead multi-program teams and external committees/coalitions
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment
• Direct or indirect experience with health care benefits configuration
• Perform user acceptance testing of health care benefits
• Experience participating in cross-functional work groups
• Experience with Covered California (Commercial) requirements