Duties & Responsibilities:
Assist in the on-going evaluation of configuration for new and existing claims business rules including member benefits, claims editing, reference data and system functionality within the claims processing system.
Analyze explanation of coverage documents to assist with determining best approach for configuring benefits offered including member cost shares, deductibles and out-of-pocket maximums.
Assist in the setup of code sets and defining pre-authorization guidelines used in claims configuration to drive application of medical policy and accurate claims payment.
Liaison with applicable departments to gather claims configuration requirements and provide feedback to stakeholders regarding feasibility of claims business rule and program changes.
Collect and analyze data to assess and resolve operational obstacles to claims configuration design optimization.
Perform root-cause analysis on claims configuration issues across all products, document results and present business impact analysis for proposed claims configuration changes.
Develop explanatory information for other departments to better understand claims configuration across products.
Identify ways to enhance performance management and operational reports related to new claims configuration processes.
Monitor existing system functionality and make claims configuration recommendations, where appropriate, to maintain acceptable levels of automation in claims adjudication and accurate claims payment.
Aid in the creation test scripts, including regression testing cases, to validate claims configuration against source documentation.
Assist with organizing the release of claims configuration changes to production to reduce the potential for migration conflict.
Ensure the quality and integrity of claims configuration change requests using production validation and audit strategies.
Provide project and informational updates to management as available and/or assigned.
Collaborate with business units to understand strategic goals and promote an environment conducive to creativity, change and information exchange.
Additional duties as assigned
Minimum Qualifications:
Proficiency in medical terminology, medical coding (CPT4, ICD9 or ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
Previous managed care/health plan experience in an operations department where you have you have been responsible for implementing or configuring claims business into plan systems.
Experience utilizing analysis tools such as SQL, SAS, Alteryx, AWS, Python, and/or Tableau.
Experience delivering claims configuration processes within an Operations or Product Management environment.
Experience gathering and communicating complex claims configuration requirements in a simple and easy to understand manner to other staff. As the SME, the Claims Configuration Analyst will need to effectively communicate with all levels of the organization, including technical staff, internal non-technical staff, testing teams, and business stakeholders.
Experience gathering and converting data into written narratives that will be used for updating project stakeholders and to make recommendations on claims configuration system changes needed.
Hands-on experience with rules based table driven claims and eligibility administration systems (i.e. PowerMHS or any other claims processing systems).
Experience using project tracking, testing and requirement tools (i.e. MS Project, SharePoint or any other time management system).
Experience with MS Excel functions that include creating standardized reports, utilizing vLookups, pivot tables, filtering and formulas to generate desired results.
High school diploma or GED from an accredited institution.
Preferred Qualifications:
Experience with claims editing software such as ClaimsXten, Cotiviti, Optum
Payment Integrity experience prepay and/or post-pay
Certified Professional Coder (CPC) or Medical Billing and Coding certification highly preferred
Experience with reimbursement methodologies
Demonstrate consistent multi-tasking skills and planning for prioritizing workload within tight deadlines.
Experience troubleshooting and solving claims configuration related issues.
Experience with MS Access functions that include to running queries, Macros and building tables for reporting purposes.
Bachelors degree or higher from an accredited institution
Compliance & Regulatory Responsibilities: N/ALicense/Certification: NAWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
