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Sr. Medical Claims Analyst
To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by providing superior quality, competitive value and outstanding service and is primarily concerned with the analyzing and accounting for the medical expenses of Health First Health Plans, Inc. This position will be required to perform complex and detailed financial analysis of the medical expenses, and act in an advisory capacity; making recommendations to management. Additionally, this position will perform peer reviews of reconciliations, journal entries and other items, as directed by management.
• Maintain GL accounts related to medical expense by verifying data, analyzing trends, reconciling transactions, preparing journal entries and resolving all discrepancies.
• Complete account reconciliations of all Balance Sheet items related to medical expenses and pharmacy expenses/rebates.
• Regularly review the P&L, providing effective and timely feedback of the medical claims, including identifying and explaining all variances.
• Reconcile medical claims to core systems and identify the cause of any discrepancies.
• Assist in monitoring the month-end close process to ensure timeliness of tasks.
• Provide support in ensuring the timeliness and accuracy of audit PBCs.
• Maintain the general ledger accounting and reconciliation of Health Plan’s medical claims.
• Prepare medical claims reports for management and other departments, as required.
• Monitor PMPM for HFHP with the focus on identifying Key Drivers (as related to Medical Expenses and Pharmacy).
• Maintain current information with respect to the accounting for medical expenses from GAAP and STAT perspectives, and communicate significant changes to appropriate personnel.
• Prepare Notes to the Financial Statements related to medical claims.
• Review contracts for compliance and financial implications.
• Prepare year-end audit schedules as required.
• Assist various departments in the annual budgeting
• Assist various departments in the annual budgeting process through utilization of historical projections and upcoming changes.
• Collaborate with the Actuarial Department on medical expense topics.
• This position requires IT system and financial understanding and how to accurately present subledger data from multiple Health First IT systems (Peoplesoft, AMISYS, & EPSI) cross walking to the general ledger.
• Review account reconciliations, journal entries, reports and other work product as requested by management.
• Review Statutory Supplemental Exhibits related to medical claims.
• Review large claims monthly estimate to Actuary.
• Prepare the Shared Savings Agreement Reconciliation.
• Identify areas for efficiency improvements and provide Leadership with recommendations.
• Prepare financial statement account reconciliations of medical expenses that support audit requirements, internal budgeting needs, fiscal year, calendar year, line of business, and market segmentation.
• Utilize financial data analytics of medical expenses to provide information and recommendations to the Health Plans’ Leadership.
• Respond timely and accurately to requests for information and reporting.
• Participate in special projects as required.
• Responsible for meeting the HFHP close deadlines and milestones.
• B.S. in business administration, finance, accounting, or related field, from an accredited college or university required. MBA or CPA desired.
• Minimum of five years of experience in general ledger accounting required.
• Minimum of three years of experience in a Health Plan or related medical field preferred.
• Minimum of three years of experience in financial analysis.
• Overall understanding of financial systems used by Health First, including the incoming and outgoing EDI transmissions of data, the posting of financial data between multiple computer systems, and the configuration tables within the computer systems.
• Prior experience and knowledge in the use of Peoplesoft preferred.
• Proficient in Microsoft Office products (SQL, Excel, PowerPoint, Word, Outlook)
• Time management and priority setting skills
• Possess excellent analytical and problem solving skills.
• Possess strong computer abilities and communication skills.
• Demonstrates the ability to relate well with all customers and peers.
• Ability to prioritize and organize to maximize quality, value, and service.
Time: Full time
Updated: 7/30/2019 5:33:56 PM