Business Analyst Sr, Claims, Covered

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Business Analyst Sr, Claims, Covered California
and help shape the future of healthcare where you’ll be an integral part of our Claims Administration
team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be
Full Telework
.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Business Analyst Sr (Claims-Covered California) will support the Claims Administration department by translating comprehensive business needs into actionable analytical and reporting solutions. You will be responsible for handling complex inquiries, analyzing claims adjudication errors, coordinating user acceptance testing and delivering training on new Facets logic. You will support staff on issues related to California Department of Managed Health Care (DMHC), Department of Healthcare Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) claims regulations, reference guides, All Plan Letters (APLs) and other applicable regulatory guidance affecting all lines of business.

You will develop and maintain subject matter expertise (SME) for all lines of business, evaluate the impact of process and system configuration changes and provide guidance to the department. Together, we are building a stronger, more equitable health system.

• 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, Med Learn 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 work groups 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…