Description
Hours:8-5
Experience Requirements:
3 years experience in health insurance or managed care environment
3 years experience in claims processing/resolution
2 years of the any of following: membership, benefits, provider contracts &
pricing, medical reviews, referral authorizations and code review and fee
schedules
Scope of project: Business configuration of benefits, authorizations, provider,
finance and general
Top three skills:
Proficiency in medical terminology, medical coding (CPT4, ICD9/, and HCPCS),
provider contract concepts and common claims processing/resolution practices
Strong experience in documentation, research and reporting
Strong analytical and problem solving skills
Top 5 daily responsibilities:
Ensures the provider, authorization and benefits configuration meets
established business rules and procedures
Loads new contracts/authorization/benefit configuration into Xcelys
Performs problem resolution of configuration issues
Consults with relevant contract manager or business analyst to determine
appropriate interpretation and configuration of contract terms
Develops, documents and executes test plans for configuration testing and
validate accuracy of data loaded
Top 3 Personality Characteristics: Analytical, team player, self-driven
Education Requirements: Bachelor's degree in business, health care or other
applicable field [or] 4 additional years of equivalent experience
The Configuration Analyst will understand the types of provider contracting
arrangements and/or benefits administration data elements that need to be
configured in the existing application (the host processing system), and other
platform applications to support the accurate and timely payment of claims for
the Regions’ Claims systems. Tests new releases, makes recommendations on
system enhancements, and evaluates contracts for configuration which includes
system capabilities. Consults with appropriate internal partners on issues of
interpretation. The Configuration Analyst works with the Product Managers and
Developers to define, code, configure and maintain detailed provider/benefit
services and provider/benefit plans designs for the applications that require
benefit information. The Configuration Analyst helps to bring products to
market that meet customer (eg, member, broker, consultant, employer, etc.)
needs and expectations and ensures that product and operational goals are
achieved. The Configuration Analyst makes sure benefits are well defined and
can be configured in all applications that require benefit data/provider
contract data. The incumbent provides consultation and support to all other
employees responsible for configuring benefits into CLIENT'S benefit
systems. The incumbent also ensures that the benefit coding definitions are
consistent across the organization. The incumbent will provide subject matter expertise
throughout the organization for benefit coding, billing and benefit
configuration and ensure consistency and compliance of benefit coding
definitions across applications. The Configuration Analyst clearly understands
the products and healthcare benefit services offered to our customers,
including cost share, limits, accumulators, and regulatory rules and
guidelines. The Configuration analyst function will leverage applicable
components of the Product Development Management Process (PDMP) or similar processes
and Comprehensive Delivery Process (CDP) or similar processes to bring CLIENTproducts to the
• Performs Configuration Activities (which may include at least one of the
following: Institutional and Provider Contracts, Benefits Authorizations, and/or
General Configuration such as System Edit Rules, Fee Schedules updates, etc.)
in Diamond Claims Processing system resulting in 100% claim payments consistent
with the contractual arrangement(s) made with the Provider, and according to
the Groups Evidence of Coverage (EOC)
• Ensures the provider, authorization and benefits configuration meets
established business rules and procedures.
• Modifies the provider contract, authorization rules and benefit plan
configuration as required.
• Loads new contracts/authorization/benefit configuration into Diamond.
• Uses MACESS workflow to monitor contract updates and contract(s) matrix/grid.
• Performs problem resolution of configuration issues.
• Consults with relevant Contract Manger or business analyst to determine
appropriate interpretation and configuration of contract terms.
• Maintains detailed knowledge and understanding of Diamond rules relative to
claims payment.
• Analyzes provider contracts to determine the best approach for loading data
elements into the claim processing system
• Analyzes benefit explanation of coverage to determine best approach for
loading benefits plan offered including co-pays, out-of-pocket maximums and
state/regulatory benefits
• Analyzes medical management requirement to determine best approach for
loading authorization rules into the claims processing system
• Develops, documents and executes test plans for configuration testing and
validate accuracy of data loaded
• Performs problem resolution of configuration issues and documents results for
the repository
• Coordinates research and resolution of debarred and sanctioned providers and
ensures communication of required system updates to Provider Contracting and
Claims Operations
• Conducts research and resolution of claim match rules and authorization rules
and communicates required system updates to Medical Management