- Direct Placement
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For, "Favorite Training Program and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
CLAIMS CONFIGURATION ANALYST I
Under the supervision of the Claims Systems Configuration Supervisor, The Claims Configuration Analyst I is responsible for the configuration and data maintenance within the payment processing system and related databases and applications. The position is accountable for the accuracy and quality of the payment processing system set-up affecting the claims adjudication and payment process.
- Responsible for reviewing contractual provisions together with Federal, State and company guidelines to determine if the contractual terms can be administered as proposed. Work with contracting staff to formulate other solutions whenever proposed contractual provisions cannot be configured.
- The timely design, configuration, testing, loading and maintenance of contract terms in the claims processing system.
- Maintains the Federal, State and other reimbursement fee schedules in the claims processing system timely. Participate in Claims Department staff meetings, and other activities as needed.
- Creating or updating any code sets maintained in the claims processing system.
- Monitor Federal and State websites to assure that required changes affecting claims adjudication and payments are implemented accordingly.
- Ensure appropriate documentation is maintained for tracking any created or updated record in the claims processing system.
- Perform pre-adjudication claims review (testing) to ensure proper configuration was used.
- Formulate and disseminate written communication regarding coding, fee schedule and system related updates.
- Responding to system inquiries and troubleshoot claims system configuration issues.
- May lead and coordinate teams in cross-functional projects related to provider reimbursement.
- Any other duties as required to ensure Health Plan operations are successful.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance.
SKILLS & QUALIFICATIONS
- High School Diploma required. Bachelor’s degree in computer science, mathematics, accounting or business administration preferred.
- Three (3) or more years of experience performing the job functions of a Claims Configuration Specialist and/or three (3) or more years in a business/system analysis or configuration role or relative experience required.
- Configuration experience using one of the following claims processing systems: AMISYS, Diamond, EZ-CAP, FACETS, IDX, iKA, MediTrac (HSP), Tapestry or Xcelys.
- Experience in creating and running basic queries using MS Access or equivalent software.
- Configuration experience using one or more of the claims processing systems mentioned above, processing Medicare and/or Medi-Cal managed care claims, CMS and Medi-Cal billing and payment guidelines, developing SQL queries using MS MySQL, SSRS, Crystal Reports or other equivalent software preferred.
- Working knowledge and experience with CPT, HCPCS, ICD, Revenue, DRG and other industry standard code sets.
- Working knowledge of basic to intermediate claims system configuration concepts.
COMPENSATION | POSITION CLASSIFICATION
- Commensurate with Experience
- Benefited | Full-Time | Exempt