Lead Business Analyst-Claims Configuration Job in Aurora, Colorado US
Lead Business Analyst-Claims Configuration
Job Summary: The Senior Configuration Analyst will understand and interpret provider contracts, benefits, authorizations and general configuration requirements to translate into Xcelys configuration components that support the claim adjudication process. The analyst will be responsible for analysis, system design and input of authorization, claims general and/plan benefit data elements in Xcelys, the host processing system, and other platform applications to support accurate and timely payment of claims. Essential Functions: - Performs configuration activities, which may include at least one of the following: Institutional and Provider Contracts, Benefits, Authorizations, and/or General Configuration such as System Edit Rules, Fee Schedules updates, etc.) in Diamond Claims Processing system resulting in consistent payments with the contractual provider arrangement(s) and according to the Groups Evidence of Coverage (EOC) - Ensures the provider, authorization and benefits configuration meets established business rules and procedures - Modifies the provider contract, authorization rules and benefit plan configuration as required - Loads new contracts/ authorizations/ benefit configuration into Xcelys - Uses MACESS workflow to monitor contract updates and contract(s) matrix/grid. - Performs problem resolution of configuration issues - Consults with relevant Contract Manger or business analyst to determine appropriate interpretation and configuration of contract terms - Maintains detailed knowledge and understanding of Xcelys rules relative to claims payment - Analyzes provider contracts to determine the best approach for loading data elements into the claim processing system - Analyzes benefit explanation of coverage to determine the best approach for loading benefits plans offered, including co-pays, out-of-pocket maximums and state/regulatory benefits - Analyzes medical management requirement to determine best approach for loading authorization rules into Xcelys - Develops documentation and executes test plans for configuration testing and validating the accuracy of data loaded - Performs problem resolution of configuration issues and documents results - Coordinates research and resolution of debarred and sanctioned providers and ensures communication of required system updates to Provider Contracting and Claims Operations - Conducts research and resolution of claim match rules and authorization rules and communicates required system updates to Medical Management Qualifications: Basic Qualifications: - Bachelor's degree in business, health care or other applicable field; or, 4 additional years of equivalent experience - 3 years experience in health insurance or managed care environment - 3 years experience in claims processing/resolution - 2 years of the any of following: membership, benefits, provider contracts pricing, medical reviews, referral authorizations and code review and fee schedules - Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related deliverables - Basic understanding of relational databases - Strong experience in documentation, research and reporting - Strong analytical and problem solving skills - Excellent interpersonal, communication, and listening skills - Proficiency in medical terminology, medical coding (CPT4, ICD9, and HCPCS), provider contract concepts and common claims processing/resolution practices - Proficiency in Microsoft Office Preferred Qualifications: - Experience in system design and analysis (provider contract or benefits administration) - Experience in claims processing - Experience interpreting and relaying Kaiser Permanente Health Plan benefits and services - Experience in systems testing or user acceptance testing - Knowledgeable of state and federal regulations - Proficiency in MS Access and query-based tools