Duties & Responsibilities :

• Lead and deliver projects related to the development and configuration of new business, member benefits and products, claims editing, reference data and their enhancements including claims configuration improvements, compliance and systems enhancements.

• Follow the annual product development processes to manage major claims configuration projects, including claims business rule set up outlier management.

• Interpret specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to claims configuration set up parameters.

• Translate complex high-level business requirements into functional requirements, specified to an appropriate level of detail.

• Provide expert support to the claims configuration process in addition to providing multifaceted triage and configuration troubleshooting assistance to other Healthfirst business areas.

• Identify and lead the configuration of medical cost savings and automation opportunities through strong analytical skills, process improvement and innovative claims configurations.

• Identify and analyze trends as a result of researching and responding to claims configuration requests, problem reports, and inquiries.

• Identify areas of improvement in existing work processes, and provide guidance.

• Establish claims configuration management policies, procedures and tools. Assist with development of claims configuration standards and best practices.

• Assess overall claims configuration change in scope and undertake work planning for new projects.

• Develop clear, concise documentation that describe claims configuration defect trends so that this information can be used to develop workflow requirements.

• Ensure that business requirements for claims configuration change requests are clearly understood, documented, communicated, tested, and delivered. Maintain claims configuration change documentation to assist other HF operational areas in administering products and benefits.

• Responsible for the quality and integrity of claims configuration change requests through the use of production validation and audit strategies.

• Responsible for organizing release of claims configuration changes to production to reduce the potential for migration conflict.

• Ensure claims configuration test scripts and audit tools, including regression testing cases, are appropriate to validate system configuration changes completed. Serve as claims configuration expert in reviewing end-to-end testing results.

• Lead, plan, direct and coordinate activities of others (non-direct reports) to meet claims configuration deadlines.

• Develop and maintain project timelines, meeting notes, issues resolution documentation, and develop vehicles of communication of this information throughout HF, and externally when appropriate.

• Develop and deliver claims configuration progress reports, proposals, requirements documentation and presentations to Senior Management as needed.

• Additional duties as assigned.

Minimum Qualifications :

• Experience utilizing analysis tools such as SQL, SAS, Alteryx, AWS, Python, and/or Tableau.

• Proficiency in medical terminology, medical coding (CPT4, ICD9 or ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

• Experience working with and leading cross-functional and level team members in claims configuration deliverables

• Experience with data analysis and query tools that utilize functions that include creating standardized reports, utilizing VLOOKUPs, pivot tables, filtering, and formulas.

• Hands-on experience with, and knowledge of, rules-based table-driven claims and eligibility administration systems.

• Experience using project tracking, testing and requirement tools (i.e. MS Project, SharePoint or any other time management system).

• Experience with Power MHS or other claims processing systems necessary.

• Comprehensive knowledge of managed care industry and product administration/implementation.

• Experience creating and delivering presentations using MS PowerPoint and MS Word.

• Associate degree from an accredited institution or HS Diplom.a or GED from an accredited Institution with equivalent work experience.

Preferred Qualifications:

• Experience with claims editing software such as ClaimsXten, Cotiviti, Optum

• Payment Integrity experience prepay and/or post-pay

• Certified Professional Coder (CPC) or Medical Billing and Coding certification highly preferred

• Experience with reimbursement methodologies

• Supervisory or leadership experience including; coaching, mentoring and training direct reports.

• Expert critical thinking and advanced organizational skills.

• Bachelor's Degree from an accredited institution.

Compliance & Regulatory Responsibilities: N/A

License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.