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Community Health Options - Remote, ME

posted 6 days ago

Remote, ME
Insurance Carriers and Related Activities

About the position

The Health Plan Configuration and Benefit Analyst is responsible for the identification, creation and implementation of solutions which will result in the efficient, accurate, and quality configuration and maintenance of Community Health Options claim adjudication platform. The Health Plan Configuration and Benefit Analyst consults with assigned operational areas to support operations-identified requirements and ensures timely configuration and implementation of selected solutions either by directly configuring the solution or providing specifications and/or instructions for configuration of the solution.

Responsibilities

  • Lead the development of business requirements, and solution design process when implementing new plans and products
  • Maintaining and updating requests for ICD-9, ICD-0 and/or CPT code changes
  • Supports the Configuration Team (BCT) and all aspects of the benefit configuration process
  • Assists with auditing, troubleshooting and resolving claim adjudication issues relating to system configuration
  • Creates and maintains claims based CARC/RARC codes
  • Maintains year to year conversion tables (including supplemental tables)
  • Supports the maintenance of our code editing and pricing software solution
  • Performs System Testing (including Patches, upgrades and new configuration)
  • Configures or other related applications, as assigned
  • Accurately and reliably maintains, documents and tests configuration
  • Analyzes existing and proposed business requirements prior to implementation
  • Documents system configuration workflows and process documents
  • Diagnoses and resolves system configuration problems
  • Acts as liaison with operations, (i.e., IT, Claims, Provider Relations and Finance)
  • Maintains an up-to-date knowledge of regulatory changes impacting benefit administration (e.g. ICD-10, ASC, DRG, CPT, HCPCS etc.)
  • Assists with translating benefits into system configuration parameters
  • Ensures compliance with the health plan policies for complete, accurate and consistent benefit plan design, resulting in appropriate benefit administration and data integrity
  • Reviews and revises business and plan design requirements for system set-ups and configuration
  • Assist in communicating issues and opportunities for improvement regarding the system enhancements
  • Assists with creating and maintaining provider, and member reference materials that reflect appropriate benefits for all programs
  • Compiles information and prepares reports, as well as analysis of the results of benefit configuration adverse findings, including appropriate recommendations
  • Other projects as assigned

Requirements

  • Bachelors degree, or a combination of related work experience and education
  • At least three years or more of experience in a healthcare plan and/or claims processing environment
  • Health Rules Payor experience required
  • Strong knowledge of medical benefits administration and other healthcare concepts
  • Advanced coding skills and knowledge of ICD-9, ICD-10 and/or CPT codes; understanding of professional, outpatient and/or inpatient billing requirements, DRG methodology, as well as knowledge of the AHA and NCCI coding
  • Proven analytical experience
  • Proficiency in the Microsoft Office Suite
  • Strong relationship-building skills
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