Well, to answer this question, you need to tell the general roles and responsibilities with respect to Healthcare domain. That means, you need to answer in such a way that the interviewer should get a feel that you really have some good experience in healthcare domain as a Business Analyst. Below are few points to answer this question.
I usually host the meetings with developers, Quality Analysts, Stake holders where we discuss about the current project progress, road blocks and discuss about pending questions that usually need answers from subject matter experts and stake holders. Usually Quality analyst and developers list out some questions while the development work is in progress. As a business analyst I answer the questions. But If I am not sure then I bring these questions in meetings to discuss with stake holders.
We also discuss about existing timelines and if we are on par with the initial time frames, if QA leads ask more time then we discuss the possibilities.
When Testing team test the application they have to send their testcases, test plans to me to review. I as a business analyst review those testcases to see if they meet /cover the business requirements. If not I let them know to write additional testcases to cover those.
I give my daily status to project managers. I also read the CMS.Gov website to update my skills and to know the latest updates in Healthcare industry and government mandates if any.
I gain knowledge in various Fee schedules changes for various states so that the pricing for each healthcare service is to be properly billed by providers and payed by payers.
I also update my knowledge on various new procedure codes, revenue codes and changes in payments in those CPT codes. I let developers and Quality analysts know about any termination of new CPT codes, revenue codes or anything that is important for them to know.
A business analyst must have a a very good understanding of business. Business analyst should know how the business works and know the new changes in business flows. He/She should know the entire hierarchy of the business. But knowing the business does not help unless you can explain that to other teams of the organization. In order to explain in pictorial form, use case diagrams help in a big way. Use case diagrams play important role in Business analyst career and any changes to the business during the course of the project development, the use case diagrams will go through lot of changes and the updated diagrams will be send to all underlying teams.
You may know more about how to draw use case diagrams in our website.
As a business analyst I have excellent knowledge on various tools such as MS Excel, MS Word, HP ALM tool for requirements and testcase documentation. I also have working knowledge on SQL server where I write some sql queries to access database tables.
Well in Healthcare domain, we use Class, Plan, Product, Procedure codes, Revenue codes, Diagnosis codes, Providers, Members/Subscribers, Medical claims, Hospital claims, Physicians.
Medical claims are the claims that an insurance company (Payer) receives from a Physician about his services to a patient (Subscriber of the insurance company).
Hospital claims are the claims that an Insurance firm receives from Hospital for the services it rendered to a patient.
Claims are usually will be received in paper form or electronic claims. Paper claims if received from a physician or hospital will be manually entered in the system. If claims are received in electronic form through EDI transactions. Electronic forms are directly will be saved into database in Insurance company.
Date of service, Procedure code, revenue codes, Diagnosis codes, Price for each service line, deductible, Copay, Coinsurance, Allowed amount for the claim, Disallowed amount in the total claim, Subscriber, Provider.
A Group will have various sub groups, and Sub groups will have Subscribers or Members.
Various products are assigned to Class/Plan combinations.
There is an agreement configured for each Provider who is having a contract with that Insurance company.
Every product will have various payment procedures based on copay, deductibles that are particularly assigned to a product.
Medicare is a USA govt health insurance program which will be offered to those who are above 65 years of old. Where as Medicaid is also a USA govt health insurance program which will be offered to low income people.
Right now the age limit is 65 years and some discussions are going on to decrease the age limit.
The providers or Hospitals need to pass certain parameters in order to be eligible to participate in medicare program. They should be in a position to provide certain healthcare services that are listed by govt.
EDI is: Electronic data interchange and HIPAA is health insurance portability and accountability. HIPAA is a set of protocols or rules set for the privacy of the individuals.
EDI is used to transfer the medical related data in the form of Electronic data transfer.
COB is coordination of benefits and is used mainly when an individual has two insurance policies and in this case how to adjudicate the claim? the whole process is to pay the exact amount which is required.
EOB is explanation of benefits which is a detailed explanation given by insurance company to its policy holder regarding a claim.