Reinsurance Analyst

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

Onsite: daily onsite requirement based on the essential functions of the job

Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position is Remote within the state of AZ only. This Remote work opportunity requires residency, and work to be performed, within the State of Arizona.

Purpose of the job

The Recoveries Analyst’s primary line of business is Medicaid. Primary purpose of the Analyst is to research and review all claims and use best practices in the recovery of any eligible stop-loss reimbursement. (Level 1)

The Recoveries Department Sr serves as the department lead for both the Medicare and Medicaid reinsurance lines of business. Provides support to the Reinsurance manager by taking the lead in all managerial functions, as in hosting meetings, reporting data and adding unification within all areas of the company. Primary purpose of the Sr is to provide leadership and educate best practices in the recovery of any eligible stop-loss reimbursement. (Level 2)

Qualifications

REQUIRED QUALIFICATIONS

1. Required Work Experience

2 years of experience in health plan reinsurance or claims unit or AHCCCS administration (Level 1)

3 years of experience in health plan reinsurance or claims unit or AHCCCS administration (Level 2)

2. Required Education

High School Diploma or GED

3. Required Licenses

N/A

4. Required Certifications

N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

N/A

2. Preferred Education

Bachelor’s degree in accounting, business or related field of study

3. Preferred Licenses

N/A

4. Preferred Certifications

N/A

ESSENTIALJOB FUNCTIONS AND RESPONSIBILITIES

Level 1

• •Assist in the day-to-day activities for the reinsurance department.
• •Identify and manage Transplant Reinsurance claims/cases in a timely and efficient manner by:
• •In coordination with Medical Service’s transplant coordinator to create and maintain transplant cases and stages with AHCCCS
• •Review transplant log to ensure all cases are created and monitor stage and component payment.
• •Transplant reinsurance cases are entered and maintained in PMMIS and encounters are tracked and balanced against PMMIS screen RI113 to ensure proper balancing prior to component submission.

• •Identify and manage Catastrophic Reinsurance claims/cases in a timely and efficient manner by:
• •Submit Annual Catastrophic reinsurance renewal letters to AHCCCS Medical Management within 30 days of the beginning of each contract year to ensure timely creation of Catastrophic Reinsurance cases

• •Coordinate with Claims department to ensure proper processing of all Medicaid reinsurance claims.
• •Ensure all reinsurance claims/CRN are encountered and associating according to AHCCCS or Medicaid Business Segment’s rates
• •Adhere to AHCCCS timely filing limits to ensure proper reimbursement.
• •Review AHCCCS reinsurance reports (Case Summary, Remittance Advice, Case Initiation and Case Reconciliation) monthly to ensure proper reinsurance reimburse.
• •Work directly with Accounting and Data Warehouse to maintain accurate Medicaid reinsurance reconciliation.
• •Maintain current working knowledge of AHCCCS reinsurance manual, procedures, and requirements.
• •Review high dollar claims report to ensure all reinsurance is captured.
• •Provide Motivation, encouragement and be a role model to others internal and external of the company.

Level 2 - SR

• •Assist in the day-to-day activities for the reinsurance department.
• •Identify and manage Transplant Reinsurance claims/cases in a timely and efficient manner by:
• •In coordination with Medical Service’s transplant coordinator to create and maintain transplant cases and stages with AHCCCS
• •Review transplant log to ensure all cases are created and monitor stage and component payment.
• •Transplant reinsurance cases are entered and maintained in PMMIS and encounters are tracked and balanced against PMMIS screen RI113 to ensure proper balancing prior to component submission.
• •Identify and manage Catastrophic Reinsurance claims/cases in a timely and efficient manner by:
• •Submit Annual Catastrophic reinsurance renewal letters to AHCCCS Medical Management within 30 days of the beginning of each contract year to ensure timely creation of Catastrophic Reinsurance cases
• •Coordinate with Claims department to ensure proper processing of all reinsurance claims.
• •Ensure all reinsurance claims/CRN are encountered and associating according to AHCCCS or Medicaid Business Segment’s rates.
• •Adhere to timely filing limits to ensure proper reimbursement.
• •Review AHCCCS reinsurance reports (Case Summary, Remittance Advice, Case Initiation and Case Reconciliation) monthly to ensure proper reinsurance reimburse.
• •Work directly with Accounting and Data Warehouse to maintain accurate reinsurance reconciliation.
• •Maintain current working knowledge of AHCCCS reinsurance manual, procedures, and requirements.
• •Review high dollar claims report to ensure all reinsurance is captured.
• •Provide Motivation, encouragement instruction to subordinates.

All levels

• •Each progressive level includes the ability to perform the essential functions of any lower levels.
• •Perform all other duties as assigned.
• •The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

REQUIRED COMPETENCIES

1. Required Job Skills (Level 1 and 2)

Knowledge of healthcare and system design (including Oracle); ability to communicate effectively orally and in writing; ability to establish and maintain effective working relationships with others, both within the corporation and externally; knowledge of accounts payable and financial reporting; knowledge in the usage of PowerPoint, Word, and Excel preferred. Analytical knowledge necessary to generate reports based on available data and then make decisions based on reported data. Capable of investigative and analytical research. Health plan accounting experience preferred.

Knowledge of reinsurance department guidelines, including but not limited to recovery, recoupments, refund posting and COB verification.

Knowledge of Medicaid and Medicare coverage and regulations; understanding of Claims Processing; Knowledge of AHCCCS guidelines and reinsurance requirements regarding reinsurance.

General knowledge of Excel, Word, Beginner SQL, MedMc, QNXT.

2. Required Professional Competencies

Be a team player and have a drive for process improvem