Medicare Supplement Claims Research Analyst
20 days ago
Atlanta
Job DescriptionJob Summary: The Medicare Supplement Claims Research Analyst serves as a subject matter expert in Medicare Supplement claims, coding guidelines and regulatory compliance. This role is responsible for reviewing, analyzing, and adjudicating claims to ensure accuracy, payment integrity and compliance with company and CMS policies. The Research Analyst interprets and applies complex regulatory and clinical guidance, translating it into actionable claim edit logic and rule sets that drive automated claims adjudication. The Research Analyst develops, maintains, and optimizes claim edit logic to ensure alignment with current policies and industry standards, supports fraud, waste and abuse prevention, and prepares reports and presentation for management. Leveraging data analytics and claims management systems, the Research Analyst identifies trends, recommends process improvements, and collaborates with cross-functional teams to drive cost savings and service excellence. Strong analytical research, communication skills, adaptability, and a commitment to ethical standards are essential. Key Responsibilities: Reference Library and Policy Governance • Architect and maintain a centralized version-controlled Reference Library for all edit and adjudication policies ensuring rapid retrieval and audit traceability., • Define structure, taxonomy, and standard fields (i.e., owner, effective/last reviewed, approvals, citations)., • Guide periodic reviews and updates; maintain version history and citation integrity. Claim Edit Logic Development and Optimization • Translate Medicare policies, fee schedules, and coding guidelines into actionable claim edit logic and rule sets for automated claims adjudication, • Specify trigger and exclusion criteria using real claim data elements; develop guardrails and hierarchies for payment integrity rule development., • Test, validate, and document logic changes for system configuration and audit readiness. Data Analytics and Trend Analysis • Develop predictive models to identify emerging fraud/overpayment patterns, operational leakage, and cost saving opportunities., • Quantify impact of edit logic and recommended rule updates or process changes., • Analyze claims data to identify potential fraud, waste, and abuse; collaborate with internal teams to investigate suspicious activity., • Support the development and refinement of algorithms for fraud detection. Regulatory Compliance and Policy Translation • Interpret and apply Medicare policies, coding guidelines (CPT, HCPCS, ICD), and regulatory requirements to claims processing and edit logic., • Convert authoritative regulatory and clinical guidance into plain language job aids and policy pages for consistent use by Claim Examiners and Customer Service Representatives. Change Control, Traceability, and Audit Readiness • Link policy pages, rule IDs, configuration tickets, test validation for end-to-end traceability., • Maintain complete change logs and version history for all logic and policy updates., • Prepare documentation packets for internal and external audits. Stakeholder Collaboration and Enablement • Facilitate resolution of complex claims issues and drive alignment with CMS policies., • Provide expert guidance and support to Claim Examiners and Customer Service Representatives regarding claim-related inquiries and escalations. Continuous Improvement • Identify opportunities for process improvements and efficiencies in claim indexing and queue management., • Stay informed about industry trends, best practices, and regulatory changes; recommend and implement process improvements to enhance claims accuracy and operational efficiency. Qualifications: Experience: • 3+years of experience in healthcare claims analysis, medical coding, payment integrity or healthcare data analytics., • Experience with Medicare payment methodologies and reimbursement rules., • Experience with clinical coding (CPT, HCPCS, ICD, NDC) and regulatory research preferred. Certifications: • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA) or similar preferred credentials. Skills: Technical and Analytical: • Advanced proficiency in SQL and Excel; experience with data visualization tools (Tableau, Power BI) and large datasets., • Ability to aggregate, filter, and tabulate results from complex healthcare data sources., • Experienced writing business logic for claims edits and translating regulatory/clinical references into actionable rules., • Familiarity with claims management systems and healthcare payment platforms. Coding and Regulatory: • Deep understanding of medial coding systems (CPT, HCPCS, ICD, DRG, NCD) and healthcare reimbursement methodologies., • Ability to research, interpret and apply regulatory updates and Medicare policies to claims logic and edit development. Communication and Collaboration: • Excellent verbal and written communication skills; able to explain technical concepts to non-technical audiences and document logic/rationale for edits., • Ability to work independently and collaboratively in cross-functional teams (technical, business operations, provider facing). Quality and Process Improvement • Strong attention to detail and commitment to accuracy in edit development, testing, and documentation., • Experience in quality assurance, UAT testing and continuous improvement of claims editing. Problem Solving and Initiative: • Demonstrated ability to analyze root causes, troubleshoot issues and propose solutions for claims editing and payment integrity challenges., • Proactive in identifying opportunities for edit optimization, regulatory compliance and operational efficiency. Work Environment / Physical Requirements: The work environment is a standard office setting with typical office equipment. This role involves professional collaboration with colleagues and clients. Responsibilities may involve extended periods of sitting, occasional walking between departments or meeting rooms, and periodic standing, reaching, stooping, and lifting office items weighing up to 25 pounds.