Health Plan Configuration Analyst

About the Job

Responsible for analyzing business requirements identifying process improvements and collaborating with cross-functional teams to implement appropriate changes. Provides both operational support and analysis of claims and/or configuration related items. Responsible for interpreting health plan benefits fee schedules claims edits provider agreement/contracts to assist third party vendor(s) with update and maintenance of core claim and ancillary systems. Assists with UAT and post validation of benefits and pricing to ensure successful configuration integration and accurate and timely payment of claims.

• Performs user acceptance testing and operational readiness for all lines of business programs and program enhancements ensuring all end-to-end operational impacts assessed requirements defined operations documentation completed (e.g., process flows policies and procedures) communications delivered and ongoing operations support established.
• Gathers business requirements and works with external vendors to ensure accurate and timely benefit configuration.
• Performs root cause analysis to understand claim anomalies and/or trends and identifies opportunities for improvement.
• Serves as subject matter expert and will work with other functional areas to respond to all configuration and claim related requests inquiries and escalations.
• Applies previous experience and knowledge to research and resolve minor to moderate claim/provider issues pending claims and provides guidance to third party vendor(s) as needed.
• Participates in meetings and on committees as assigned.

• Bachelor's degree required or
  • One (1) year of relevant education may be substituted for one (1) year of required work experience.
• Minimum of 3 years of experience in a health plan or managed care setting, specifically supporting Claims Configuration, Customer Service, and Enrollment.
• One (1) year of relevant professional-level work experience may be substituted for one (1) year of required education.

• Certified Professional Coder (CPC) Certification preferred.

• Strong understanding of operational activities around claims enrollment call center utilization management etc. related data.
• Prior experience in medical billing claims auditing and claims analysis.
• An in-depth understanding of national reimbursement mechanisms as well as local regulatory environment.
• Ability to convey verbal and written information effectively.
• Ability to follow verbal and written instructions.

This position has a hiring range of

USD $65,062.00 - USD $ /Yr.