01Responsibilities
Support Optum medical Claims Editing System (CES) for AMS clientsPartner with Client Leader to establish and strategize how to achieve savings targetsIdentify, research, develop, and size, new prepayment editing opportunities for use in Claims Editing System (CES) edit application for assigned healthcare payersProactively review profiling system rules, using coding, policy, reimbursement, clinical, and claims background to determine which rules can be presented to the payer for new medical cost savings opportunitiesPresent new edit concepts to clients during Governance meetings, effectively explaining the rule's intent, support, anticipated exposure, and influencing the client to adopt the ruleExecute the 'Rule Approval' processGenerate innovative editing ideas that can be scaled across the organizationStay current on client configuration and new CES functionality in order to recommend the most effective rule designConduct root cause analysis, including investigation into Knowledge Base updates, LCD updates, and rule logic defects, to recognize and remediate escalated issuesInterpret complex reimbursement language, policies, and methodologiesDefine, create and maintain rule requirementsAcquire and maintain working knowledge of multiple platform specific knowledge, customer customizations, databases, file systems and architecture that support the CES applicationReview quarterly Knowledge Base release to determine custom rule impact and maintenance needsBuilding out non-proprietary and proprietary rule library: proactively share information with internal
