Business Analyst- Operations Oversight Appeals & Cost Recovery

GEHA (Government Employees Health Association, Inc., pronounced G.E.H.A.) is a nonprofit member association that provides medical and dental benefits to more than two million federal employees and retirees, military retirees and their families. We celebrate diversity and are committed to creating an inclusive environment for all employees.

GEHA has one mission: To empower federal workers to be healthy and well.

Offering one of the largest medical and dental benefit provider networks available to federal employees in the United States, GEHA empowers health and wellness by meeting its members where they are, when they need care. We serve our members with products they value and a personalized customer experience, sustained by a nimble and efficient organization. 

The Business Analyst – Operations Performance serves on projects of moderate to significant complexity. Interacts with internal and external customers to identify needs and determine solutions that deliver maximum value. Maintains a strict adherence to departmental standards related to documentation and artifacts and provides peer review for the work of other business analysts.

SKILLS

Duties and Responsibilities

• Demonstrated ability to analyze problems, probe facts, identify and question assumptions and find creative and effective solutions to meet business goals without compromising customer satisfaction.
• Collect, organize, and analyze information within vendor systems and reports.
• Collaborate with vendor partners to ensure seamless alignment of business processes with the vendor system.
• Evaluate the effectiveness of integration efforts and support continuous improvement initiatives.
• Develop and deliver reports and presentations to stakeholders, including senior management to drive informed decision-making and ensure transparency in efforts.
• Foster a work environment of continuous improvement Collaborate with internal stakeholders to include senior management to ensure comprehensive and efficient resolution of issues and development of process improvement.
• Maintains knowledge of GEHA’s policies, procedures, and contract provisions.
• Participate in working sessions with cross functional teams to ensure requirements are clearly defined and provide clear expectations for success.
• Comprehensively review and evaluate second level appeals. Determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
• Provide written acknowledgment of member for second level appeals.
• Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
• Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, policies and procedures, best practices, and performance issues.
• Prepare written responses to OPM for second level appeals that appropriately address each complainant’s issues and are structurally accurate.
• Plans, schedules, and facilitates meetings.
• Develops, tracks, monitors, and communicates project progress against the project plan.
• Coordinates the input, process, support, and communication with all functional areas that impact or are impacted by project scope, business value, risk, and resource requirements.
• Ensures integration of the project activities to meet schedule, deliverables, and manages process changes to achieve customer requirements.
• NSA/IDR review and reporting
• Audits claims, reports or electronic files for accuracy, benefit payment, and compliance with policies and procedures
• Prepares and presents quality audit reports for management to identify trends, issues, and performance.
• Manage the yearly ID card file.
• Complete yearly 1095B and 1099 process.
• Complete audit reviews of QA work/output from UMR to include, but not limited to: Calls, claims, eligibility & enrollment, appeals, payment integrity and Provider data management.
• Calibrate with QA team at UMR to ensure results are in alignment; escalate when outcomes cannot be aligned.
• Complete audit reviews
• Actively engage and demonstrate characteristics of a collaborative team member.
• Other duties as assigned.

Education Requirements

• Associates degree in a related field.
• Additional years of qualifying work experience may be considered in lieu of formal education.

Experience Requirements

• Requires three (3) years of progressively responsible heath plan experience.
• Experience creating collaborative and productive relationships with internal and/or external partners.
• Requires highly effective verbal and written communication skills and good organizational skills.
• Requires knowledge of medical terminology, medical codes, and related reference materials.
• Excellent problem solving, organizational, and analytical abilities.
• Experience with Microsoft Excel

Work-at-home requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

How we value you

• Competitive pay/salary ranges
• Incentive plan
• Health/Vision/Dental benefits effective day one
• 401(k) retirement plan:  company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution   
• Robust employee well-being program
• Paid Time Off
• Personal Community Enrichment Time
• Company-provided Basic Life and AD&D
• Company-provided Short-Term & Long-Term Disability
• Tuition Assistance Program

While this is a remote opportunity, at this time GEHA does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.

Please note that the salary information is a general guideline only.  GEHA considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.

The annual base salary range for this position is $63,578 - $89,622 USD.

GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees. Our diversity drives innovation deepens connections and strengthens our organization.

GEHA is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.