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Healthfirst Claims Implementation Analyst (Hybrid - WFH and on-site) in New York, New York

Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to a fully vaccinated in-office environment. You must be vaccinated to work in our offices, even if you are partially remote. If you are selected to interview for this role, we will explain our vaccination policy and ensure you are comfortable moving forward with further interviews based on your work location.

Job Description Summary:

The Claims Implementation Analyst is responsible for assisting in analyzing, implementing and reporting of required claims configuration business rules. The Implementation Analyst will assist management by developing and maintaining reporting tool and processes, querying and analyzing data, identifying root causes, recommending and supporting decision making. The Implementation Analyst owns project goals by developing project plans, establishing deadlines, monitoring milestone completion, providing timely reporting of issues that impact progress and resolving conflicts. This includes documenting and prioritizing assignments. This is a fast-paced and rapidly growing environment. The role is a Hybrid role which offers the opportunity to work from home (WFH) 2 to 3 days a week and in the office 2 to 3 days a week.

Duties & Responsibilities

  • Analyze contract terms, prepare fee schedules and accurately document file changes into the claims processing system

  • Research and identify published updates to payment methodologies, fee schedules and claims editing policies from Medicare, Medicaid, and third-party sources.

  • Responsible for the overall success of implementations including applicable testing and results verification before sign-off and Production.

  • Assist in the on-going audit of configurations for new and existing claims business rules within the claims processing system.

  • Identify claims configuration and contract implementation defects and improve departmental performance by supporting quality, operation efficiency and production goals thru reporting.

  • Develop and maintain new and existing reporting tools, databases and processes.

  • Create and maintain scripts/cases to meet requirements of functional specifications and ensure proper system functionality and quality outcomes including claims configuration, provider set up, reimbursement methodology and core claims system changes.

  • Perform training and quality assurance on mass claim adjudications and automated data load processes.

  • Query and manipulate claims configuration and claim data to root cause, trend, summarize findings and offer recommendations.

  • Work departmentally and interdepartmentally to recommend and implement modifications to existing claims configuration audits and claim reporting functions.

  • Review technical specifications to ensure the Claims Configuration Department business requirements are adequately implemented based on technical planning documents.

  • Ensure post implementation accuracy of claims configuration implementations and mass claim adjudication projects.

  • Recommend changes to address deficiencies and/or further improve and streamline performance based on analysis findings.

  • Prepare routine reports as needed (financial, quality, production, operational efficiency, etc.).

  • Track and report updates on individual work assignments and other projects within established timeframes

  • Assess and prepare to address the operational impacts, workflow, and training issues of the assigned project(s).

  • Complete other projects and duties as assigned.

Minimum Qualifications:

  • Managed care, commercial health plan (or other healthcare related) experience where you have performed claim or data analysis.

  • Experience gathering and communicating business requirements in a simple and easy to understand manner to other staff.

  • Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

  • Experience in Microsoft Excel creating formulas and pivot tables and in using macros and the v-LOOKUP function.

  • Experience creating databases and reports using Microsoft Access or other similar database software.

  • Experience using report writing tools, i.e. Crystal Reports or SAS.

  • Experience creating presentations in Microsoft PowerPoint.

  • Experience analyzing data, data mining, managing projects and identifying trends.

  • High School Diploma from an accredited school.

Preferred Qualifications:

  • Experience with facility reimbursement methodologies (i.e. Diagnostic Related Groups, DRG; Ambulatory Payment Classification, APC; or Ambulatory Patient Group, APG, etc.).

  • Understanding of payment and billing principles for physician or other professional services (i.e. ancillary, behavioral health, Long Term Care, etc.).

  • Experience managing reports in Microsoft Outlook or other communication base systems in order to optimize utilization.

  • General understanding of software design and development.

  • Ability to communicate clearly in written and verbal form.

  • Ability to create effective job aides and review them with key stakeholders at multiple levels of the department and organization.

  • Analyze current and potential systems and serve as a resource and subject matter expert (SME) on all aspects of project plan development to support business strategies.

  • Assist in the development of process and system efficiency to reduce the number of exceptions and to facilitate or influence change, ultimately improving our competitive position and/or optimal performance.

  • Ability and willingness to handle increasing workload and responsibility.

  • Ability to solve problems under time pressure, with frequent interruptions. Capability of multi-tasking including strong organizational and time management skills.

  • Experience with MHS and/or MACESS systems a plus.

  • Knowledge of Medicare and Medicaid programs and reimbursement methodologies a plus.

  • Knowledge of healthcare claims processing practices in a managed care setting a plus.

  • Bachelor's Degree from an accredited institution.

Compliance & Regulatory Responsibilities: N/A

License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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All hiring and recruitment at Healthfirst is transacted with a valid “” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.