- Translate data movement requirements into technical ETL design.
- Develop ETL workflows and mappings to extract, transform, and load data into target environments.
- Develop test plans and perform unit testing of own work.
- Create supporting documentation for new ETL processes.
- Identify opportunities for improving efficiency and effectiveness of processes and controls.
- Use standard ETL toolsets to develop and test ETL workflows.
- Work closely with data analysts within Data Warehouse Team to gain an understanding of the business processes and corporate data.
- Determine impacts of data warehouse structures and information flows due to changes in business or technical requirements.
- Perform, root cause analysis, and contribute to the remediation planning and implementation.
- Perform data quality analysis, report data quality issues, and propose solutions for data quality management.
- Participate in on-call rotation (after hours, nights and weekends).
- Identify and conduct thorough investigations of complex member disputes to prepare complete case files and respond to regulatory inquiries.
- Communicate all necessary verbal and written communications related to the decision of an appeal including but not limited to: members, providers, legal entities, etc. within regulatory timeframes.
- Schedule, coordinate, and facilitate meetings with the review committee, the member, and any other ad hoc representatives.
- Respond to customer inquiries, in a courteous and efficient manner regarding eligibility, verification of benefits and claims payment status via telephone or in person, on an as available/needed basis.
- Investigate customer written inquiries and coordinate with proper internal departments to ensure timely responses are completed.
- Investigate, coordinate, and reply to all written complaints and other regulatory inquires received by the company ensuring that handling of grievances, appeals, and regulatory inquiries comply with applicable state and federal statutes, regulations, and sub-regulatory guidance.
- Develop health plan training programs and conducts training for health plan staff relating to: identifying complaints/grievances/appeals; appropriate documentation and reporting such as disputes; government requirements involving the dispute resolution process and health plan policies and procedures for the various dispute resolution processes.
- Build and maintain provider and facility records including adds, changes and terminations within the claims adjudication system (HealthLink).
- Sets up and maintains provider (SER), facility (FAC), place of service (POS), PCP Location (LOC), PCP status, and network records for adds, changes and terminations for contracted providers.
- Processes updates to vendor (VEN) records, 835 and EFT builds, and add claim alerts when needed.
- Preps and loads provider information into HealthLink through an import spreadsheet and direct entry and maintenance in HealthLink.
- Builds and maintains Practice Locations, Facilities, Practitioners and Contracts in the Provider Database (eVIPs).
- Sets up and maintains Contracts, Facilities, Practice Locations, Practitioners, and networks. for adds, changes and terminations for contracted entities.
- Enters and maintains providers, practitioners, and facilities while linking them to the contracts and networks including prepping and loading data manually, through dynamic import utility, through BOT automation, and mass update and mass insert processes.
- Configures and maintains Data Masters, Reference tables, Networks and Address Masters.
- Performs provider licensure, NPI, Medicare and Medicaid validation.
- Performs departmental and corporate project work and other duties as assigned by Manager.
- Conducts query requests and runs ad-hoc reports as needed.
- Submits Provider and Facility rosters for self-funded business.
- Conducts research based on claims received, communication from the providers, and source verification documentation for responding to CRMs, providers, and claims inquiries.
- Process enrollment transactions, including entering new member benefit selections and disenrolling members from the system, and processing member benefit changes or eligibility requirements
- Process, review and compare electronic and roster files, investigate and update other insurance, and process other enrollment-related reports
- Work closely with members, group contacts, agents and regulatory agencies to answer enrollment-related and eligibility inquiries and ensure all enrollment regulations and requirements are met
- Identify and resolve issues, including reconciling any eligibility discrepancies
- Understand and remain knowledgeable of all enrollment regulations, including but not limited to: effective dates, termination dates and other eligibility-related regulations and requirements
- Process all invoices submitted to Oracle accounts payable system daily – verify general ledger coding, approver routing, and assess for use tax
- Supplier profile set-up and maintenance – collection of W9 and ACH forms, ensure all routine supplier payments are paid monthly, and existing supplier profiles are maintained in Oracle
- Batch invoices and pay suppliers by check, ACH, and outsourcing options, meeting payment deadlines timely & consistently
- Review monthly credit card transaction logs for each corporate cardholder, validate and reconcile receipts to statements, ensure cored documentation and coding of expenses to general ledger accounts
- Support compliant monthly and annual filings and financial close, including: monthly Sales & Use Tax returns, monthly Medicaid-related reporting, and annual reconciliation & filing of 1099 NEC and MISC, prepare GAAP journal entries and perform account reconciliations as assigned
- Maintenance and support of Data Management, Reporting, and Analytics Platforms. Responsible for:
- Software deployment, configuration, and upgrades.
- Stability, performance monitoring, remediation, and improvements.
- Serves as the primary liaison with the managed services providers, infrastructure, application development and security teams.
- Capacity, growth, and resource planning.
- Disaster recovery, planning, and testing.
- Support for Development Teams:
- Consults and provides support to Business Intelligence and ETL Developers, and Data Analysts.
- Enhances team documentation to aid in training and improving off-hour support.
- Provides appropriate notification to nursing staff of all requests and hospitalizations requiring further review.
- Makes approval determinations according to written protocols and guidelines as appropriate. Refers any medical questions or potential denial determinations to nursing staff for further review.
- Assists in the medical review process for referrals, prior authorizations, inpatient reviews and claims reviews by obtaining appropriate supporting information and documentation to assist in making necessity and benefit determinations as well as reconsiderations.
- Provides telephone customer service for members, providers, and other Health System or Quartz staff regarding authorization requests, hospitalizations and claim questions.
- Strategy Development
- Formulate IAM strategies aligned with organizational goals.
- Evaluate and select IAM technologies to meet business requirements.
- Work with all parties to include project sponsors, vendors, and IT operations groups.
- Interface with management and user community to understand business needs, implement security best practices, and identify opportunities for improving security and compliance.
- Access Control
- Design and implement access control policies and procedures.
- Ensure processes for access provisioning and access re-certifications are consistent and repeatable.
- Enforce policies and procedures to ensure only authorized personnel have access to information in compliance with Cybersecurity standards.
- Oversee user provisioning and de-provisioning process.
- Compliance
- Drive annual compliance certification and oversee all related controls and documentation management as required.
- Ensure IAM practices comply with industry regulations and standards.
- Lead efforts to pass audits related to access controls.
- Provide oversight, guidance, and development of requirements for vendor selection for new and replacement technologies within the Information Security footprint.
- Continuous Improvement
- Monitor IAM performance metrics and identify areas for improvement.
- Implement continuous improvement initiatives to enhance IAM capabilities.
- Team Leadership
- Supervise a team of IAM professionals.
- Provide mentorship, training, and guidance to team members.
- Provide project support for supervisor / EDI staff that are delegating tasks and review the project plan to determine when efforts are due. Manage tasks, provide status of efforts, and complete tasks.
- Manage the production support queue of items and respond to all incoming emails within established SLAs (Service Level Agreements).
- Assist other Business Analysts with test and investigation of production issues and testing, problem solving by loading claims, running jobs, reporting results, and moving files for the support and testing of the business needs.
- Work with IT to set routines for trading partners and problem resolution by creating requests to communicate changes and implement new customer requests.
- Build business and technical knowledge by reading documentation, questions, and gaining experience with issues related to the business.
- Document and update EDI business processes that are owned by the project team.
Perform designated executive support duties requiring judgment, initiative, and knowledge of office functions for the designated executive(s)/ director(s). Responsible for providing excellent quality service and maintaining excellent working relationships for internal and external customers. This may include such duties as:
- Schedule internal and external meetings/events and appointments via Outlook for leaders as requested (includes scheduling, room reservations, equipment set up and catering orders). Proactive maintenance of calendars.
- Prepare, compose, and type letters/memos/emails, graphs, charts, studies, presentations, miscellaneous reports, and research for assigned leader.
- Prepare and distribute meeting agendas and materials and attend meetings and take minutes as assigned. Transcribe minutes with appropriate follow-up on action items.
- Screen and direct telephone calls, mail, and email to the appropriate person within the organization. Obtain appropriate signatures as needed and requested on documents/contracts/agreements.
- Make purchase orders as needed, reconcile company credit card, allocate purchases to appropriate budget cost centers, create expense reports and help others troubleshoot fiscal processes.
- Coordinate and manage pharmacy benefit programs, including formulary management, prior authorizations, and medication adherence programs.
- Collaborate with pharmacy providers to ensure timely and accurate prescription fulfillment and delivery.
- Analyze pharmacy data and trends to identify opportunities for cost savings, quality improvement, and enhanced member satisfaction.
- Develop and implement innovative strategies to optimize medication therapy and improve health outcomes.
- Serve as a subject matter expert on pharmacy-related issues, providing guidance and support to internal teams and external partners.
- Consult with leadership to understand business requirements and data needs; recommend solutions that address unexpressed and/or underlying needs
- Serve as a subject matter expert in advanced data techniques including modeling, integration, visualization, mining, discovery, AI/ML, natural language processing, and solution design
- Assemble data sets from disparate sources and analyze using appropriate quantitative methodologies, computations frameworks, and systems
- Develop algorithms, predictive models, and create prototype systems, visualizations, and simulations that test and support key business decisions
- Develop and deliver automated data products that offer actionable insights and accurate predictions
- Optimize models to improve sensitivity and/or specificity for data observations and offer corrective action recommendations to improve the efficacy and/or efficiency of reports, processes, and/or controls
- Present data-related findings at internal meetings with non-technical audiences and/or leadership teams to effectively influence strategy
- Document and share processes and analyses consistent with organizational best practices, and ensuring compliance with security and internal controls
- Serve as the primary point of contact for reporting, analytics, and insights across Quartz and provider sponsors
- Collaborate with executive colleagues and other stakeholders on data-driven initiatives and analyses
- Oversee prioritization of key data-related initiatives for Quartz, provider sponsors, and any other stakeholders, including identifying opportunities, considerations, and actions for the bi-directional exchange of data between organizations that drive improvement, cost savings, and efficiencies
- Empower and build a high-performing team of data professionals who understand Quartz’s culture, objectives, and strategies to apply effective data analyses and expertise to address organizational concerns, challenges, risks, and opportunities.
- Assess the organization’s current capabilities and develop a strategic plan to address any gaps or challenges.
- Prioritize data quality, data reporting, data requests, and data needs to ensure accurate and useful business outcomes and actionable insights for Quartz, provider sponsors, and other stakeholders
- Design, develop, and maintain functional data repositories for operational and production data from the data warehouse and other vendor data sources
- Promote effective teamwork and actively eliminate impediments to collaboration between departments and between Quartz and its provider sponsors
- Enhance Quartz’s enterprise-wide data and reporting capabilities
- Optimize technology in the data space to create a competitive advantage within the healthcare and health insurance industries
- Promote data literacy and a companywide data-driven culture
- Establish policies and practices that improve user access to data while ensuring data quality, credibility, protection, and privacy through effective data governance
- Develop and implement strategic formularies and pharmacy programs to improve medication adherence, reduce costs, and enhance patient satisfaction.
- Collaborate cross-functionally internally and with external partners to identify, develop, prioritize, and implement outcome-based pharmacy activities:
- Quartz Pharmaceutical Care Management (PCM) Program
- Quartz Medical Drug Pharmacy Programs.
- Quartz Pharmacy Programs.
- Clinical Client Consultancy, Sales Support and Client On-boarding.
- Trend Management and Reporting.
- Provides leadership, support and guidance to Team, Pharmacy Department, Clinical Services and Quartz Health Plan.
- Develop and manage SOPs to govern the Pharmacy Programs and Strategy area.
- Serve as subject matter experts and provide expertise and assistance to Quartz departments including Customer Service, Sales, Underwriting, Provider Relations, Marketing, Finance, Medical Management, Behavioral Health and Operations.
- Ensure compliance of pharmacy benefit management activities with appropriate regulatory (OCI, DOI, CMS, DHS) and accreditation (NCQA) organizations in collaboration with internal areas including assessment of new government program requirements and determine appropriate compliance strategies and implement.
- Process and finalize all requests within turnaround time (TAT) utilizing guidelines and other applicable regulatory requirements
- Enter coverage requests into the system and prioritize as required
- Check formulary alternatives, review tried and failed medications
- Utilize drug references and verify the drug being requested is indicated and approved for the condition
- Document all related information regarding the coverage decision
- Respond to coverage requests by faxing status to the physician
- Conforms to defined roles & responsibilities and rules of engagement between coverage decisions processing and clinical decision making
- Partners with assigned clinical pharmacists to accurately and efficiently complete coverage decisions
- Accountable to achieve productivity and accuracy standards
- Analyzes, researches, and resolves coverage decision processing issues including making written or telephone inquiries to obtain information from PBM, members, physicians, or pharmacies.
- Manage Medicare Prime/Quartz secondary skilled nursing facility prior authorization process, including:
- Reviewing and processing select prior authorization requests for completeness, reach out to members for more information and to answer their questions, and processing denials for lack of information
- Review covered benefit requests against medical necessity criteria, policies, and certificates of coverage to process approval and benefit denials
- Prepare medical records and case notes for approvals, and present denials to Medical Director for further review, as needed
- Conduct telephonic customer service and problem solving for members and providers regarding authorization requests, hospitalizations, and claims questions
- Triage outpatient and customer service urgent prior authorization requests
- Assist with healthcare service coordination - collaborate with RN team to identify and prioritize high needs / risk cases, research and identify appropriate in-network services & assess specialist wait times, and assist members with care coordination and problem solving
- Coordinate peer to peer requests between physicians
- Perform Health Plan Transition initial screening/intake for new member coordination of care and between applicable departments
- Medical documentation and reporting - send appropriate notifications to members, providers, and facilities according to established processes & policies
- Architects, designs, enhances, and supports delivery of data integrations, enterprise data warehouse, data marts, and data submissions.
- Identifies, develops, and documents data acquisition and delivery requirements to meet business and customer needs.
- Facilitates group discussions and join data design sessions with the business area subject matter experts.
- Designs data models and data processing flows for data acquisition, reporting and analysis.
- Develops, implements, and maintains standards and procedures concerning the design and use of data for compilation and delivery.
- Coordinates data solution delivery and supports data analysis and data development staff as necessary in the development and maintenance of data implementations.
- Queries, analyzes, and interprets complex data stored in the source and target systems.
- Play a role in supporting the company’s data governance program to provide definitions, visibility, and access controls for corporate data.
- Works with business stakeholders to assist with data-related technical issues and supports their data infrastructure needs.
- Collaborate with business users, external vendors and/or government entities to obtain data requirements for new analytics applications and data feeds or enhancement of existing products.
- Uncover appropriate sources of data for proposed application or data warehousing extension profiling data to ensure fitness for business purpose.
- Coordinate business requirements for the data and provide consultation to internal stakeholders to support their data needs.
- Understand source and target data structures, using standard data tools to review required data and fully profile the data to analyze its ability to meet the business needs.
- Complete impact assessments and ad hoc analyses to ensure that production issues and other reported deficiencies are adequately understood and resolved by updating requirements.
- Translate requirements into technical requirement specifications, appropriately documenting the solution via Report Specifications, Data Flow Diagrams, and Source to Target (STT) documents.
- Act as a senior analyst by directing junior analysts on company protocols, business data, and technical skill.
- Create and refine tools and workflows to efficiently collect and translate organizational data and reporting needs.
