Product Configuration Quality Analyst

Inland Empire Health Plan•Rancho Cucamonga, CA

4d•$80,059 - $106,059•Hybrid

About The Position

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Product System Configuration Supervisor, the Product Configuration Quality Analyst is responsible for ensuring the integrity of all claims system configuration created and maintained by the Product System Configuration team. The Product Configuration Quality Analyst audits claims system configured by the Application Architects and Analysts to ensure accurate adjudication of claims. Ensure all Business Rules are configured correctly in the claims system. Support testing efforts within an agile team and execute all levels of testing (System, Data validation, Integration and Regression). The Product Configuration Quality Analyst utilizes quality auditing tools, identifies trainings needs, and collaborates on effective and efficient methods for accurate and quality system configuration. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Three (3) years of experience of auditing complex system configuration required
Three (3) years of experience in Managed Care required
Experience with claims review required
Bachelor’s degree in IT or Business from an accredited institution required
In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position: one (1) year of general healthcare experience plus three (3) years of claims analysis experience is required
Comprehensive knowledge and understanding of: Regulatory compliance and how configuration changes affect regulatory adherence
Comprehensive knowledge and understanding of: CPT, HCPCS, Revenue, ICD-10 Coding rules and guidelines
Comprehensive knowledge and understanding of: General managed care operations and delegated plan models
Comprehensive knowledge and understanding of: CMS, DHCS, DMHC, NCQA rules and regulations
Comprehensive knowledge and understanding of: Encounters, EDI submissions, provider web portals, integrated NCCI applications, and overall data mapping
Comprehensive knowledge and understanding of: System and application process integrations and algorithms
Comprehensive knowledge and understanding of: Medicare, Medi-Cal, and Covered California benefit structure and regulatory billing guidelines
Comprehensive knowledge and understanding of: Medicare, Medi-Cal, and Covered California claim processing guidelines
Comprehensive knowledge and understanding of: Relational database structure
Comprehensive knowledge and understanding of: Testing and audit methodologies
Strong skills in performing independent root cause analysis, developing test cases, and documenting findings
Skills in Microsoft Excel, Access, and SQL applications
Exceptional problem solving and critical thinking skills
Strong presentation and written communication skills
Ability to interpret regulatory changes and assess the need for configuration updates
Ability to identify training gaps and advise leadership on quality trends
Proven ability to: Operate as an independent reviewer and provide objective assessments under tight schedules
Proven ability to: Work independently and solve complex problems with little to no assistance
Proven ability to: Effectively manage competing priorities
Proven ability to: Ensure compliance and quality assurance standards are met

Nice To Haves

Experience in claims analysis/auditing preferred
Experience in major managed care system migration/implementation preferred

Responsibilities

Audit team output, analyze and assess data reports, and validate system configuration accuracy against contract interpretation, business rules, and regulatory requirements.
Ensure errors are corrected and escalated issues are resolved within a timely manner.
Report findings and trends to leadership to further support requirements of accuracy and productivity.
Partner with the Product System Configuration Supervisor to define and uphold quality standards for Application Architects and Analysts performing claims system configuration (test coverage, evidence standards, defect SLAs).
Identify data integrity gaps, recommend process improvements, and flag training needs.
Provide insights and feedback to Product System Configuration Supervisor.
Generate and audit quality reports (billing/handling practices, adjudication results, exception trends).
Trigger improvement actions with Analysts.
Own the weekly review of the Claim Check Run Audit and reconcile issues/discrepancies.
Conduct in-depth root cause analysis of claims and integrated system configuration related issues that arise from claims and integrated system errors.
Classify defects (e.g., large/difficult/complex) using quantitative thresholds and clear language.
Review regulatory guidelines to determine if claims system configuration updates are required.
Identify, communicate, and present on impact of system enhancements or configuration changes on integrated systems and processes related to regulatory guideline updates.
Track compliance in QA matrices.
Partner in the development of configuration standards and best practice guides for maintaining efficiency, accuracy, automation and successful integration with internal and external systems and programs.
Analyze and identify system configuration based on claims auto adjudication standard metrics and business operational requirements to identify systematic quality risks and control improvements.
Own and maintain a library of system requirements, specifications, test cases, defect logs, and test results.
Ensure traceability from requirement to test evidence.
Own UAT (User Acceptance Testing) test plan preparation and test execution of product delivery initiative(s), crossing multiple applications.
Develop and run automated test scripts and evaluate results.
Work with Compliance teams to determine solutions to help comply with regulations, guidelines, and All Plan Letters (APLs).
Attend DHCS meetings, as needed.
Develop and maintain policies, procedures, and training guidelines on behalf of the Product System Configuration team.
Assist with claims system configuration updates as needed.
Facilitate audit meetings to keep discussions focused, productive, and aligned with objective.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.