Business Process Specialist

1 week ago

Houston, United States Pride Health Full time

Title:: Business Process Specialist

Location:: Houston, TX

Duties:

  • To support and develop programs aligned with Health Plan strategic goals through effective and timely assessment and equitable distribution of resources and assignments, education and implementation of processes and procedures that provide and maintain a cost-effective provider network Health Plan.
  • Through participation in Medical Policy, Reimbursement Committee, and other workgroups as needed, provides support for the facilitation of process and/or system changes.
  • Proposes, implements, and supports quality control measures related to practice and/or system changes that impact claims adjudication.
  • Reviews current and newly implemented processes to ensure accurate reports and/or other deliverables.
  • Leads collaborations with other departments to ensure compliance standards are met.
  • Process and workflow management for audit response, contract adherence, and regulatory compliance functions.
  • Prioritizes key project tasks and deliverables and identifies risks, issues, and dependencies.


Skills:

  • Must demonstrate the ability to achieve effective issue resolution.
  • Must have excellent written and verbal communication skills, and the ability to interact with various individuals
  • and handle several complex situations simultaneously.
  • Must have leadership, creativity, integrity initiative, and sound problem-solving skills.
  • Must provide attention to detail and follow-up.


Knowledge, Skills, and Abilities:

  • Knowledge of health and human services agencies, programs, and state and federal Medicaid and CHIP laws and regulations.
  • Strong skills in analyzing and evaluating complex federal and state legislation and demonstrating through financial impact analysis.
  • Skilled in researching & analyzing medical policy and its impact on claims processing/adjudication and providing system optimization recommendation
  • Highly organized with the ability to manage several projects concurrently in a fast-paced environment and juggle competing priorities.
  • Strong skill in developing and evaluating policies and procedures, assessing risks, and making recommendations.
  • Strong written and oral communication skills, including making public presentations and writing technical information in an understandable format.
  • Skilled in project planning, evaluation, and implementation.
  • Ability to effectively facilitate meetings and maintain working relationships with staff or program stakeholders.
  • Ability to exercise creative problem-solving techniques in a highly complex environment.
  • Ability to work cooperatively as a team member in a fast-paced, deadline-orientated environment.
  • Ability to work independently and perform work with a high degree of attention to detail.
  • Proficient in the use of Microsoft Office products.
  • Performs and plans configuration changes for coding, contracts, benefits, fee schedules and claim editing rules as needed


Education: Required-

  • Bachelor's Degree- Business, Health Care Administration, Public Health, Nursing, MIS or an IS-related field.
  • Required- 2 years’ Experience in a managed care organization (MCO) or related healthcare organization.
  • A master’s degree in business, Health Care Administration, Public Health, Nursing, MIS, or an IS-related field may substitute for 2 years of required experience.

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