Since 1985, MetroPlusHealth has helped the people of New York City get quality health care at little to no cost. MetroPlusHealth is the plan of choice for over 712,000 New Yorkers, and its commercial and government-sponsored plans meet the needs of individuals, families, and workforces. The MetroPlusHealth staff speaks more than 40 languages and is as diverse as the great City it serves. MetroPlusHealth is part of NYC Health + Hospitals, the nation's largest public health system.

MetroPlusHealth is embarking on a Core Processing System transition and is seeking a highly experienced Lead Claims Business Analyst specifically focused on medical and behavioral health claims processing of government and commercial products (Medicaid, Medicare, CHP, QHP, etc.). As part of this transition, the Lead Claims Business Analyst will partner with our consultant to support the requirements gathering, process analysis, implementation, and testing activities. They will understand current state processes and translate those into future state requirements, while ensuring it aligns with the goals of the department. They will have a holistic understanding of the operational inter-connections of upstream/downstream claims processes. The Lead Claims Business Analyst will collaborate with the consultant and cross-functional stakeholders to conduct discovery/scoping sessions that will result in detailed documentation illustrating the current and future state end-to-end workflows, a thorough list of all requirements with supporting plans for implementation, and enhanced policies and procedures. In addition to these activities, the Lead Claims Business Analyst will partner with the Compliance department to ensure regulatory requirements are met. They will also assist in testing and training activities. The Lead Claims Business Analyst will work closely with the Vice President of Business Transformation and Vice President of Claims Operations to help champion the broader vision of the future state Core Processing System and will be a key support in the flawless execution of the system transition, ensuring improved processes and higher quality.

Job Description

• Serve as the main point of contact for the Claims Processing workstream.
• In partnership with our Consultant, interview stakeholders, gather data, and define/document business requirements while ensuring a comprehensive understanding of needs and objectives. This includes, but is not limited to, system configuration, workflows, reporting, and capacity plans.
• Create an inventory of current state and future state workflows for all claims processes including downstream processes (reporting, data feeds, and other applications).
• Identify any gaps in the current documentation of processes and partner with the Consultant on the creation of those.
• Understand existing gaps and/or pain points within the Claims department and collaborate with the Consultant to identify solutions for improvement.
• By working with the Consultant, identify industry best practices to enhance the claims operations and drive system improvements.
• In partnership with the Consultant and Vice President of Claims Operations, confirm that the product roadmap includes all requirements for claims processing, the configuration/development work is prioritized appropriately, and all enhancements are identified based on business value.
• Review all claims specific business requirements, workflow documentation, policies, and procedures created by the Consultant and confirm accuracy prior to sign off.
• Collaborate with our QA teams and the Consultant to define all test cases, test scenarios, and acceptance criteria.
• Assist in the testing and validation of all applications used by the Claims department against established requirements to ensure all test cases and scenarios pass.
• During testing, identify deviations from requirements and partner with the Consultant to remedy all issues.
• Contribute to the development of training materials that will be leveraged when conducting our formal training of team members.
• Review all training materials created by the Consultant to confirm accuracy and quality of materials.
• Monitor progress of the workstream and provide regular updates to stakeholders, addressing and escalating any changes in scope or roadblocks promptly.
• Ensure timeliness of all deliverables outlined in the project schedule.
• Act as a liaison between the Consultant, business stakeholders, development teams, and other critical resources, facilitating effective communication and alignment.
• Other duties as assigned

Minimum Qualifications

• Bachelor’s Degree in Business Administration or related field; and
• Proven experience (5+ years) in a Business Analyst role focused on medical claims processing and operations, experience in behavioral health claims processing preferred; or
• A satisfactory equivalent combination of education, training, and experience.
• Experience in supporting at least one core processing system migration.
• Proficiency in eliciting, documenting, and managing business and functional requirements.
• Experience with working cross functionally to have a holistic understanding of how the operations and corresponding processes work.
• Excellent analytical skills with the ability to synthesize complex information and provide actionable insights.
• Exceptional facilitation skills and proven experience at driving consensus across multiple stakeholders.
• Proven track record of successful collaboration with development teams to deliver high-quality system software.
• Knowledge of health plan industry regulations, guidelines, requirements, and policies related to provider networks, provider contracting, fee schedules, and other provider network components.
• Demonstrated experience with provider network testing/auditing/QA.
• A demonstrated track record of driving the organizational and operational changes in the day-to-day business of a high-volume operation using current and new technology, achieving service excellence.
• Proficiency in Microsoft Office – specifically Word, Excel, VISIO, and PowerPoint.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Effective written and verbal communication skills in a wide range of mediums.
• Highly detail-oriented, resourceful, and self-motivated.
• Proven presentation and organizational skills
• Exceptional problem-solving skills and a proactive approach to identifying and resolving challenge.
• Ability to effectively communicate with technical and non-technical stakeholders, translating between business needs and technical solutions.
• Strong organizational skills with the ability to manage multiple projects and priorities concurrently.
• Polished interpersonal skills with emphasis on discretion and diplomacy.