Job Summary:
The Configuration Systems Analyst II Leads and defines system requirements associated with Member Benefits, Provider Reimbursement and payment systems requirements definition, documentation, design, testing, training and implementation support using appropriate templates or analysis tools.
Essential Functions:
- Identify, manage and document the status of open issues. Develop and utilize reports to analyze and stratify data in order to address gaps and provide answers to issues identified within the department or by other departments, utilizing TriZetto or Optum for research and correction.
- Utilize available tools provided by relevant State or Federal websites to obtain pertinent Fed/State Regulatory Transmittals and Fee Schedules.
- Plan/implement new software releases including testing and training.
- Participate in meetings with business owners and users to achieve a Plan benefit design and Provider Reimbursement. Serve as liaison between IT and business areas to research requirements for IT projects, meet with decision makers to translate IT specifications and define business requirements and system goals.
- Lead review of benefits or provider reimbursement as well as identify and design appropriate changes. Lead in the development and execution of test plans and scenarios for all benefit or reimbursement designs and for the core business system and related processes.
- Provides detail analysis of efficiencies related to system enhancement/automation. Review, analyze, and document the effectiveness and efficiency of existing systems and develop strategies for improving or further leveraging these systems. Conduct preliminary studies to define needs and determine feasibility of system design.
- Audit configuration to ensure accuracy and tight internal controls to minimize fraud and abuse and overpayment related issues.
- Ensure system processes and documents exist as basis for system logic.
- Assists in resolution for potential business risk, including communication and escalation as necessary.
- Vendor management between TriZetto and CareSource.
- Applies use of tools to define requirements such as data modeling, use case analysis, workflow analysis and functional analysis.
- Perform any other job related instructions as requested
Education and Experience:
- High School Diploma or GED is required
- Bachelor’s Degree or equivalent years of relevant work experience is preferred
- Minimum of three (3) years health plan experience, to include two (2) years of configuration or clinical editing software experience is required
- Exposure to Facets is preferred
Competencies, Knowledge and Skills:
- Advanced computer skills with Microsoft Word, Excel, Access, Visio and abilities in Facets
- Proven understanding of database relationships required
- Understanding of DRG and APC reimbursement methods
- Understanding of CPT, HCPCs and ICD-CM Codes
- Knowledge of HIPAA Transaction Codes
- Critical listening and thinking skills
- Decision making/problem solving skills
- Enhanced communication skills both written and verbal
- Can work independently and within a team environment
- Attention to detail
- Understanding of the healthcare field
- Knowledge of Medicaid/Medicare
- Claims processing skills
- Proper grammar usage
- Time management skills
- Proper phone etiquette
- Customer service oriented
- Facets knowledge/training
- Proper claim coding knowledge
- Ability to be telecommuter
- Broad understanding of business considerations and functionality preferred
Licensure and Certification:
- Certified Medical Coder (CPC) is preferred
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$69,400.00 - $111,000.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.