This position is responsible for the annual and general configuration and maintenance of Advantasure's core claims system. The successful candidate will be responsible for assisting in the ongoing configuration, management, and oversight of client plan benefits and/or provider contracts.
Benefits/Plan Configuration - with a focus on adjudication logic, claims/clinical editing, processing annual Plan Benefit Packages (PBPs), updating cost share, deductibles, member out-of-pocket maximums and regulatory benefit coverage.
Interpret complex and simple provider contract methodologies and use critical thinking and problem solving to determine system configurability and solution for non-standard configuration.
Configure provider contracts including group and institutional provider contracts, interim rate letters, custom fee schedules, delegated provider contract and capitation arrangements.
Responsible for running claims through the system(s) in multiple real-life scenarios to ensure consistency in running and reporting claims, and to ensure compliance with both State and Federal CMS and Medicare Advantage regulations.
Perform unit and/or regression testing for new configuration, programming enhancements, new benefit designs, and software changes as necessary that affect claims adjudication.
Configuration Testing - with a focus to ensure the claims system is properly configured to process and adjudicate claims.
Create claims and tests/audits claims payment accuracy against benefit and contract methodologies in the claims payment system ensuring compliance with both State and Federal CMS and Medicare Advantage regulations and client specifications as specified by client plans.
Develops and improves workflows and business processes within area(s) to improve customer service, decrease operational costs, and improve overall quality.
Apply previous experience and knowledge to research, analyze and interpret data to determine appropriate configuration changes and resolve claim/encounter issues and pended claims and update system configuration as necessary.
Proactively identifies opportunities and recommends system solutions that increase automation, resolve system deficiencies, and enhance claims processing and reporting to meet and exceed business requirements and decrease operational costs.
Act as the subject matter expert regarding claims processing issues. Assists in establishing, and documenting policies and procedures, DLPs and workflows in support of standardized and accurate configuration.
Act as a liaison with Client Implementation team to define business requirements and processes as well as QA for new client implementations.
Assists personnel, both internally and externally, by answering questions, supplying information, and training in system configuration and setup.
Develops and maintains an effective working relationship with customers.
Interprets and puts into production CMS changes.
Bachelor's degree in Business Administration, Computer Science, Information Technology, Health Care, or a related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged.
Five years of experience in claims/provider contract configuration software is required. Analyst experience in operational analysis, data analysis, and problem resolution type activities is required.
Must have the ability to quickly identify, triage, diagnose, and resolve reported issues with the intent of improving the performance of the claims processing system.
Tasks and decision-making are generally independent in nature but will require collaboration with internal and external partners.
Understands health insurance and Medicare benefit administration and CMS regulations.
Knowledge of professional and institutional claims adjudication.
Coding knowledge and experience with CPT, HCPCS, ICD9, CDT, Revenue, DRG and other relevant medical and industry-standard codes
Proven experience in benefit/claims and provider contract configuration in Ika, Facets, or equivalent claims systems.
Ability to plan, organize, direct, and control projects.
Demonstrates strong analytical skills.
Excellent written and verbal communication skills.
Excellent analytical, organizational, and problem-solving skills.
Ability to lead and contribute to process improvement projects.
Ability to work successfully as both a team player and an individual contributor with little supervision.
Ability to manage multiple clients/priorities.
Significant creativity to utilize system capabilities to meet benefit design.
Ability to develop, implement, and monitor policies and procedures.
Proficient in current industry standard PC applications and systems (e.g., Access, Excel).