Senior Business Operations Analyst

Responsible for collections and/or refunds of highly complex cases. Performs functions necessary to facilitate payment recovery including research, appeals, and follow up. Identify trends, potential resolutions and escalate to manager. Provide data related to reimbursement reductions, overages, delays, and non-payment. Evaluate accuracy of contract modeling, communicate findings, and escalate as appropriate. Participate in payer meetings to resolve issues. Responsible for ensuring solutions implemented and goals achieved. Identify and monitor CMS & payor rule changes and work to ensure compliance. Minimum Education

Bachelor's Degree (Preferred)

Minimum Work Experience

5 years Related patient accounting experience required, especially related to denial mitigation and root cause analysis (Required)

Required Skills/Knowledge

Excellent working knowledge of complex contract reimbursement methodologies including transplant, global, APR DRGs among others.

Proven analytical skills including ability to make recommendations based on financial analyses.

Excellent PC skills including advanced skill proficiency in Access and Excel spreadsheet analysis.

Ability to work in a team environment with other analysts, managers, and department leaders.

Proficiency in presentation of analytical results.

Excellent working knowledge of coding & NCCI edits.

Demonstrated knowledge of managed care payer requirements in an acute hospital setting.

Demonstrated ability to facilitate team or group activities.

Excellent verbal and written communication skills.

Demonstrated ability to be flexible and to prioritize workload & decision-making skills.

Ability to analyze workflow for process improvement.

Strong organizational and coordination skills required.

Functional Accountabilities

Account Follow-up and Collections

Ensure all assigned claims are followed up and/or appealed in a timely manner as per standard operating procedure (SOP); ensure maximum recovery of reimbursement.

Follow up on all appeals to ensure receipt and processing by carrier and prevent loss to untimely appeal

Evaluate contract management expected reimbursement and follow appropriate guidelines to report and escalate.

Evaluate overpayments and process timely as per procedures

Manage large volumes of line item denials, underpayments, and overpayments, and various appeal deadlines to prioritize workload and maximize reimbursement.

Ensure written appeals are clear, concise and within timely appeal limits.

Ensure appropriate supporting documentation is included with appeals.

Analyze retracted payments to determine appropriate course of action to recover reimbursement.

Prioritize work to facilitate payment of higher account balances. Data Analysis and Issue Resolution

Manage matrix of issues & resolutions including accountable stakeholders; ensure results and escalate issues as appropriate; regularly report updates and challenges to manager

Conduct root cause analysis of issues reducing reimbursement & slowing payment cycle. Identify key issues and assist in tracking, trending and reporting.

Present data and analysis clearly to all levels of staff and management.

Meet with manager and outside departments to review issues and develop action plans.

Assist in development of solutions, training & education guidelines to resolve issues and share data with staff and management.

Appropriately engage and involve key accountable stakeholders in a collaborative manner.

Research payer & CMS policies related to revenue cycle; identify & alert stakeholders of required changes; track and ensure completions. Safety

Speak up when team members appear to exhibit unsafe behavior or performance

Continuously validate and verify information needed for decision making or documentation

Stop in the face of uncertainty and takes time to resolve the situation

Demonstrate accurate, clear and timely verbal and written communication

Actively promote safety for patients, families, visitors and co-workers

Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

Organizational Accountabilities

Performance Improvement

Understand managed care contracting & reimbursement schemes (Prof /Tech) as well as payer requirements, reimbursement policies & clinical policy bulletins and apply principles to improve performance.

Apply CMS reimbursement rules to operation to drive improved performance.

Develop knowledge of internal billing systems & edits and make recommendations to mitigate denials.

Develop detailed knowledge of internal billing coding and CDM process to identify breakdowns and resolutions.Organizational Commitment/Identification

Partner in the mission and upholds the core principles of the organization

Committed to diversity and recognizes value of cultural ethnic differences

Demonstrate personal and professional integrity

Maintain confidentiality at all timesCustomer Service

Anticipate and responds to customer needs; follows up until needs are metTeamwork/Communication

Demonstrate collaborative and respectful behavior

Partner with all team members to achieve goals

Receptive to others’ ideas and opinionsPerformance Improvement/Problem-solving

Contribute to a positive work environment

Demonstrate flexibility and willingness to change

Identify opportunities to improve clinical and administrative processes

Make appropriate decisions, using sound judgmentCost Management/Financial Responsibility

Use resources efficiently

Search for less costly ways of doing thingsOrganizational Accountabilities (Staff)

Organizational Commitment/Identification

Teamwork/Communication

Performance Improvement/Problem-solving

Cost Management/Financial Responsibility

Safety