Configuration and Coding Analyst

Avera•Sioux Falls, SD

5d•Onsite

About The Position

The Configuration & Coding Analyst is responsible for the design, configuration, implementation, testing, and ongoing support of health plan claims administration system to ensure accurate, compliant, and automated claims adjudication. This role serves as a critical link between Health Plan Operations, Clinical Services, Provider Network, Compliance, and Information Technology by translating benefit plans, provider contracts, reimbursement methodologies, medical policies, fee schedules, and regulatory requirements into system configuration. The analyst configures and maintains claims editing software and core claims system functionality, including benefits, fee schedules, coding edits, provider reimbursement rules, and authorization requirements. The position is responsible for validating claims processing and logic, maintaining coding integrity, troubleshooting configuration issues, and supporting continuous system optimization to improve automation, regulatory compliance, operational efficiency, accurate claims payment and provider coding reconsiderations.

Requirements

Certified Coding Associate (CCA) - American Health Information Management Association (AHIMA) or other nationally recognized coding organization Upon Hire or Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC) Upon Hire or Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA) Upon Hire
Epic Certification - Epic Epic Tapestry Certification or required to participate in Epic coursework and pass certification exams within 90 days of hire. within 90 Days
4-6 years Coding with knowledge and understanding of provider reimbursement methodologies, medical terminology, human anatomy, physiology, ICD-10-CM, CPT, HCPCS coding, and NCCI edits.
Demonstrated critical thinking skills through evaluation, analysis, and creative solutions.
Ability to think broadly, identifying and understanding implications to the entire organization including excellent communication, documentation and problem-solving skills.
Ability to work independently and as part of a cross-functional team.

Nice To Haves

Bachelor's in Healthcare Administration, Information Systems, or related field or Epic Tapestry Certification with 3+ years of experience.
4-6 years Experience with complex system design, preferred experience with claims adjudication platforms or ecosystems, specifically Epic Tapestry.
Background and knowledge of Health Plans operations and understanding of health plan processes, systems and regulations including claims processing, benefit configuration, enrollment and provider networks.
Including familiarity with CMS regulations, HIPAA and payer-provider contracting.
Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
Experience with Epic Chronicles and data models, Care Management or other related modules.
Familiarity with EDI (Electronic Data Interchange) formats (e.g., 834, 837, 835) and integration best practices.

Responsibilities

Design, configure, implement, test, and maintain health plan claims administration systems, including benefits, fee schedules, provider reimbursement methodologies, claims editing rules, authorization requirements, and related workflows to support accurate and automated claims adjudication.
Interpret and translate Evidence of Coverage (EOCs), Summary of Benefits and Coverage (SBCs), provider contracts, reimbursement methodologies, medical policies, coding updates, and regulatory requirements into compliant system configuration and technical specifications.
Configure and maintain claims editing software and coding logic, including ICD-10-CM, CPT, HCPCS, modifiers, NCCI edits, CARC/RARC codes, revenue codes, and reimbursement edits to ensure accurate claims pricing, payment, and compliance with coding standards and payer policies.
Perform end-to-end testing, validation, and quality assurance of system configuration changes to ensure claims adjudicate accurately according to benefit design, provider contracts, coding guidelines, and applicable federal and state regulations.
Investigate, troubleshoot, and resolve claims processing issues, payment discrepancies, suspended or denied claims, and configuration defects by conducting root cause analysis and implementing corrective system solutions.
Research, evaluate, and implement quarterly and ongoing updates to medical coding, reimbursement methodologies, regulatory requirements, and health plan policies to ensure system configurations remain current and compliant with CMS, Medicare, Medicaid, ACA, HIPAA, NCQA, and commercial payer requirements.
Develop and maintain configuration documentation, testing plans, workflow documentation, audit trails, and technical specifications to support configuration management, regulatory compliance, accreditation activities, and organizational change management.
Collaborate with Health Plan Operations, Clinical Services, Provider Network, Compliance, Finance, Information Technology, vendors, and other stakeholders to translate business requirements into effective system solutions and support enterprise health plan initiatives.
Serve as a subject matter expert for claims configuration, coding, reimbursement methodologies, and health plan system functionality by providing technical guidance, supporting production issues, participating in system implementations and upgrades, and promoting continuous operational improvement.