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 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 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 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 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 products 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