Senior Claims Business Solutions Analyst

Coordinate the operational aspects of operational services as related to accuracy and timeliness of claims transaction processing, configuration, or testing. Maintain and perform processes to monitor the outsourcing service delivery. Communicate and coordinate between user areas and the outsourcing party to minimize issues and increase productivity across all areas. Participate in company-wide operational initiatives and work with users to help define process requirements to deliver the best solution.

ESSENTIAL JOB FUNCTIONS:

• Monitor and oversee the operational areas for outsourced and retained functions.
• Serve as a business lead and advocate for functional business area in driving large complex initiatives by ensuring projects are well formulated, executed, operationalized, communicated, and align with the corporate strategic goals.
• Represent department as lead in project status meetings and provide transparency to business owner and divisional leadership in communication of project status, risks, and escalation needs.
• Identify and prioritize opportunities to create business process, workflow, or system efficiencies. Create solutions recommendations that increase productivity and profitability through innovation standardization, optimization, and automation.
• Assist with the review of all changes made to operations processing to minimize impact to members, providers, employer groups, and BCBSRI.
• Assess the impact of major system migrations and updates, monitoring the progress of resolution for all system issues impacting claims timeliness and accuracy. Review root cause analysis of system issues and ensure accuracy of all impacted operations processes; interaction with associated vendors.
• Develop, manage, track, and monitor outsourced services as related to contract deliverables, including SLA, SOW, and KPI measurements.
• Participate in monthly Outsourced Vendor Leadership meetings, attend vendor governance meetings, and maintain compliance with all developed processes.
• Serve as liaison between internal or external business customers. Serve as an escalation point for users when expectations are not met. Identify breakdown in workflows, expedite delivery of services, implement a long-term remediation plan, and work with the user community to help streamline processes and add operational efficiencies.
• Research, resolve, and document both technical and operational issues. Serve as first-level escalation point to other departments or projects in resolution of risks or issues.
• Maintain close working relationship with outsourced vendor delivery teams to support collaboration, integration, and coordination at all operational levels.
• Assist in ensuring that all claims operations processing workflows implemented meet all internal and external regulations (e.g., HIPAA, BCBSA, CMS, etc.). Assist in creating responses to any internal or external audits and, if necessary, work with the appropriate parties to resolve any negative audit findings.
• Lead and educate all members of project teams in understanding business objective, defining and monitoring project scope and financial impacts during all phases of the project development life cycle including, but not limited to, EDRC, project estimation, finance committee, and Project Investment Committee. Provide claims SME for projects assigned.
• Support organizational readiness activities through participation in development and approval of testing strategy, training, communication, and business process changes.
• Perform other duties as assigned.

QUALIFICATIONS:

• Bachelor's degree in Business Administration or a related field, or an equivalent combination of education and experience.
• Five to seven years of experience in operations managing vendor relationships.
• Three to five years of claims operations experience.

• Understanding of outsourcing and vendor oversight responsibilities and service-level agreements.
• Three to five years of claims operations experience.

• Understanding of health plan operations.
• Ability to remain calm and professional in stressful situations with customers and vendors.
• Advanced analytical skills with the ability to interpret and synthesize complex enrollment operations configuration and benefit processing.
• Good business acumen and political savvy.
• Knowledge of business process improvement-techniques and strategies.
• Excellent verbal and written communication skills.
• Negotiation skills.
• Presentation skills.
• Decision-making skills.
• Good problem-solving skills.
• Ability to interface with employees at all levels.
• Ability to effectively navigate ambiguous situations with limited direction.
• Excellent organizational skills and ability to successfully prioritize multiple tasks.
• Ability to handle multiple priorities/projects.