Claims Configuration Analyst - 8 month contract

Maryland  ‐ Onsite
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Keywords

Description

Description

Claims Configuration Analyst

*This position can work remote*

The position 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), & other platform applications to support the accurate & timely payment of claims for the Regions' Claims systems.

Tests new releases, makes recommendations on system enhancements, & evaluates contracts for configuration which includes system capabilities.

Consults w/appropriate internal partners on issues of interpretation.

Works w/the Product Mgrs & Developers to define, code, configure & maintain detailed provider/benefit services & provider/benefit plans designs for the applications that require benefit info.

Helps to bring products to market that meet customer needs & expectations & ensures that product & operational goals are achieved.

Makes sure benefits are well defined & can be configured in all applications that require benefit data/provider contract data.

Provides consultation & support to all other employees responsible for configuring benefits into benefit systems. Also ensures that the benefit coding definitions are consistent across the organization.
Provide subject matter expertise throughout the organization for benefit coding, billing & benefit configuration & ensure consistency & compliance of benefit coding definitions across applications.

The position clearly understands the products & healthcare benefit services offered to our customers, including cost share, limits, accumulators, & regulatory rules & guidelines.

The position's function will leverage applicable components of the Product Development Management Process (PDMP) or similar processes & Comprehensive Delivery Process (CDP) or similar processes to bring products to the market.

Essential Functions:
Performs configuration activities (which may include at least one of the following: Institutional & Provider Contracts, Benefits Authorizations, and/or General Configuration such as System Edit Rules, Fee Schedules updates, etc.) in Diamond Claims Processing system or other system resulting in 100% claim payments consistent w/the contractual arrangement(s) made w/the Provider, & according to the Groups Evidence of Coverage
Ensures the provider, authorization & benefits configuration meets established Business rules & procedures
Modifies the provider contract, authorization rules & benefit plan configuration as required
Loads new contracts/authorization/benefit configuration into Diamond
Uses MACESS workflow to monitor contract updates & contract(s) Matrix/grid
Consults w/relevant Contract Mgr or business analyst to determine appropriate interpretation & configuration of contract terms
Maintains detailed knowledge & 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 & state/regulatory benefits
Analyzes medical mgmt requirement to determine best approach for loading authorization rules into the claims processing system
Develops, documents & executes test plans for configuration testing & validate accuracy of data loaded
Coordinates research & resolution of debarred & sanctioned providers & ensures communication of req'd system updates to Provider Contracting & Claims Ops
Assume other duties as directed

Requirements:
Three (3) to five (5) years of experience in health insurance or managed care environment
Three (3) to five (5) years of experience in claims adjudication with an in-depth knowledge of at least two of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules
Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary followup and closure procedures for system related deliverables
Understand relational databases
Must have a strong functional knowledge of medical terminology, medical coding (CPT4, ICD9, and HCPCS), provider contract concepts and common claims adjudication practices
Intermediate proficiency in Excel
Knowledgeable of state and federal regulations
Beginner's proficiency in Access and Query tools
Understands needs of claims clients and relationships
Three (3) to five (5) years of experience in system design and analysis (provider contract or benefits administration), preferred
Two (2) - three (3) years of experience on the host claims processing system, preferred
Experience interpreting and relaying Health Plan benefits and services, preferred
Experience in systems testing or user acceptance testing, preferred
Bachelor's degree in business, health care or other applicable field
Strong experience in documentation, research and reporting
Strong analytical and problem solving skills
Excellent interpersonal, communication, & listening skills

Start date
May 2014
Duration
8 months
From
Enclipse Corp.
Published at
23.04.2014
Project ID:
698246
Contract type
Freelance
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