The Business Rule Management Analyst is responsible for ensuring the accurate, timely, and compliant submission of encounter data to the State. This position performs ongoing monitoring, analysis, and resolution of encounter errors and works collaboratively with Claims, IT, Business Owners, and other stakeholders to identify root causes and implement solutions that support successful encounter submissions.
The position is also responsible for maintaining and updating the claims adjudication system to ensure approved business rules are accurately configured and applied. The Analyst works closely with CBH Business Owners to understand business requirements, translate those requirements into system functionality, and ensure claims are adjudicated in accordance with CBH policies, contractual requirements, and established business rules.
Essential Functions:
Encounter Management & State Submission
- Monitor encounter submissions to ensure data is accurate, complete, timely, and compliant with State requirements.
- Review State encounter response files, including rejections, errors, and other exceptions, to identify trends and recurring issues.
- Analyze encounter errors and perform root-cause analysis to determine the source of discrepancies.
- Develop, document, and implement appropriate resolutions to ensure encounters are successfully submitted and accepted by the State. Complete testing to ensure resolution is valid.
- Coordinate with Claims, IT, Business Owners, and other departments to resolve encounter-related issues.
- Monitor encounter correction and resubmission activities through successful State acceptance.
- Maintain documentation of encounter issues, resolutions, system changes, and corrective actions via JIRA.
- Identify opportunities to improve encounter processes, reduce errors, and increase the efficiency and accuracy of State submissions.
- Support State audits, inquiries, and requests related to claims.
- Validate encounter-related system changes to ensure they produce the expected results prior to implementation.
Business Rules & Claims System Management
- Work with CBH Business Owners to identify, define, and document business requirements affecting claims adjudication.
- Translate approved business requirements into system business rules and configuration requirements.
- Ensure claims are adjudicated in accordance with CBH Business Owner requirements, policies, contractual obligations, and approved system specifications.
- Analyze existing business rules to determine the impact of requested changes on claims processing, encounters, providers, members, and other downstream processes.
- Participate in requirements gathering, business rule development, testing, implementation, and post-implementation validation.
- Conduct testing of new or modified business rules and document test results.
- Identify unintended impacts or conflicts between existing and proposed business rules and coordinate resolution with appropriate stakeholders.
- Maintain accurate documentation of business rules, system configurations, testing, approvals, and implementation dates.
- Participate in change control and SDLC activities associated with claims system modifications.
- Ensure system changes are appropriately reviewed, approved, documented, and implemented in accordance with CBH processes.
Analysis, Reporting & Process Improvement
- Analyze claims and encounter data to identify trends, anomalies, processing issues, and opportunities for improvement.
- Investigate discrepancies between claims adjudication results and encounter data submitted to the State.
- Recommend process and system improvements based on data analysis and identified operational issues.
- Maintain knowledge of State encounter requirements, CBH policies, claims processing requirements, and applicable business rules.
- Serve as a subject matter resource for business rules, claims adjudication, and encounter submission processes.
Key Competencies
- Strong analytical and problem-solving skills.
- Ability to perform root-cause analysis and develop sustainable solutions.
- Knowledge of claims adjudication and encounter submission processes.
- Ability to translate business requirements into system requirements and business rules.
- Strong attention to detail and data accuracy.
- Ability to interpret technical and business requirements.
- Strong written and verbal communication skills.
- Ability to work effectively with Business Owners, IT, Claims, Compliance, and other departments.
- Strong organizational and project-management skills.
- Ability to manage multiple priorities and meet State and organizational deadlines.
Position Requirements:
- Education: Associate’s degree required; Bachelor’s degree preferred
Relevant Work Experience:
- At least 3 years of experience in Claims or Behavioral Health
- Proficient in Excel and Word
- Thorough understanding and knowledge of claims submission requirements
- Strong problem solving and analysis skills
- Detail-oriented and accurate data entry skills
- Strong organizational skills
- Ability to multi-task in fast paced environment
- Sound judgment and decision making skills
- Excellent customer service attitude
- Strong teamwork, communication and interpersonal skills
- Knowledge of HIPAA EDI 5010 ASC X12 837P, 837I, 835, 277CA, TA1 and 999 transaction sets
Philadelphia Residency Requirement:
- The successful candidate must be a current Philadelphia resident or become a resident within six months of hire.
U.S. Authorization Requirement:
- CBH does not provide sponsorship for applicants requiring future work authorization. All candidates must be legally authorized to work in the United States without requiring sponsorship now or in the future.
Equal Employment Opportunity:
- We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CBH is an equal opportunity employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on all qualified individuals. This is without regard to race, ethnicity, creed, color, religion, national origin, age, sex/gender, marital status, gender identity, sexual orientation, gender identity or expression, disability, protected veteran status, genetic information or any other characteristic protected individual genetic information, or non-disqualifying physical or mental handicap or disability in each aspect of the human resources function by applicable federal, state, or local law.
Requesting An Accommodation:
- CBH is committed to providing equal employment opportunities for individuals with disabilities or religious observance, including reasonable accommodation when needed. If you are hired by CBH and require an accommodation to perform the essential functions of your role, you will be asked to participate in our accommodation process. Accommodations made to facilitate the recruiting process are not a guarantee of future or continued accommodation once hired.
- If you would like to be considered for employment opportunities with CBH and have accommodation needs for a disability or religious observance, please send us an email at [email protected]
Skills Required
- Associate's degree
- Bachelor's degree
- At least 3 years of experience in Claims or Behavioral Health
- Proficiency in Excel and Word
- Thorough understanding of claims submission requirements
- Strong problem-solving and analytical skills
- Detail-oriented and accurate data entry skills
- Strong organizational skills
- Ability to multitask in a fast-paced environment
- Sound judgment and decision-making skills
- Excellent customer service attitude
- Strong teamwork, communication, and interpersonal skills
- Knowledge of HIPAA EDI 5010 ASC X12 837P, 837I, 835, 277CA, TA1, and 999 transaction sets
- Current Philadelphia residency or residency within six months of hire
- Legal authorization to work in the United States without current or future sponsorship
What We Do
CBH is a nonprofit 501 (c)(3) corporation contracted by the City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services to manage the delivery of behavioral health services for Medicaid recipients of Philadelphia County. For more information about CBH, visit cbhphilly.org. For more than 25 years, Community Behavioral Health (CBH) has been expanding access to mental health services for Philadelphians. CBH provides access to high-quality, accountable care to improve the health and mental wellness of our Members. Our Mission: CBH provides access to high-quality accountable care to improve the health and mental wellness of our members. Our Vision: Leading innovation in whole-person care for healthy, thriving communities. Our Values: We Care. We value and appreciate our staff and service providers, believing that a healthy, happy workforce creates healthy, happy members. We show our appreciation regularly and listen to concerns. We also care deeply for the overall health of Philadelphians, knowing that a vibrant, thriving, resilient city hinges upon healthy citizens. We Empower. We are here for our employees, members, and partners. We are open and transparent, encouraging dialogue and fostering growth so we can all be our best, healthiest selves. We Connect. We’re updating our processes and technology to better serve our community and communicate more effectively and efficiently. We cultivate two-way communication, sharing our appreciation for our staff and welcoming feedback from them. We Lead. Behavioral and mental wellness is our passion, and we are experts in the field. We have been serving the Philadelphia community since 1997, and we know the industry. We cultivate close working relationships with our partners, who are also leaders in the mental health field. We are open to change and innovation to ensure the highest standard of care for all.
