- Analyze provider contracts/ pricing, designs/configure provider agreements, configuration validation, and configuration peer review.
- Communicate design to all stakeholders and varying levels of the organization.
- Present and evaluate design solutions objectively and facilitate conflict resolution.
- Define, use, and communicate design patterns and best practices in service-oriented analysis, design, and development.
- Configure new and revised claims adjudication logic within a healthcare claims system.
- Configure products/ benefits, provider agreements, fee schedules, and claims payment rules.
- Configure Claim Adjustment Reason Codes and Remittance Advice Codes.
- Quality assurance and testing within the health plan configuration system (e.g., Facets) to ensure the configuration is ready for implementation.
- Collaborate with the quality assurance team to ensure testing efforts align with system deliveries and business processes.
- Develop strategies to improve service development life cycle and governance processes.
- Develop and use enterprise service and data models.
- Quality assurance and testing.
- Analyse provider pricing.
What we're looking for (top 5 only):
- 9+ years of configuration experience working in claims configuration.
- 9+ years of experience identifying patterns within quantitative data, drawing conclusions, and recommending solutions and approaches, skilled with end-to-end issue resolution.
- 9+ years of experience in health care with emphasis on coding, financial rate setup, or claims processing in a managed care environment.
- Must be knowledgeable of medical claims data, formats, and restrictions including but not limited to Revenue Codes, Place of Service codes, ICD-10 codes, CPT Codes, and Modifiers.
- Experience in Medicaid or Medicare environments.
Recommended Additional Skills/ Experience:
- Advanced or greater level of proficiency with Microsoft Excel and Word.
- Excellent oral and written communication skills, interpersonal skills, and organizational abilities are essential.
- Ability to work effectively without supervision.
- Ability to manage multiple assignments while maintaining quality standards and meeting assigned deadlines.
- Experience leading teams of 5 or more.