Overview

Manages the configuration and maintenance of the claims system used to administer operations of current and new business for VNS Health Plan products. Oversees the translation of business rules to action. Analyzes, documents, and tests all new configurations. Prepares and delivers reports, recommendations, and updates/revisions to address existing and potential claims system issues. Works under general direction.

Compensation Range:$98,200.00 - $130,800.00 Annual

What We Provide

• Referral bonus opportunities     
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays   
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability    
• Employer-matched retirement saving funds   
• Personal and financial wellness programs    
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care   
• Generous tuition reimbursement for qualifying degrees   
• Opportunities for professional growth and career advancement    
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities  

What You Will Do

• Ensures that system configuration is completed in accordance with contractual agreements and implemented into production. Leads and/or participates in systems project life cycle development including functional specifications, configuration, testing, training, and roll out. Participates in project identification and evaluation.
• Works with Compliance to identify and implement new state and federal regulations. Oversees audit programs to ensure product and program compliance.
• Serves as subject matter expert for Medicare and Medicaid benefits administration to support Third Party Administrator (TPA) and other internal departments, including marketing and enrollment, provider network management, medical management, claims, and customer service.
• Ensures that annual benefit updates and pricing configurations are mapped, tested, documented, and loaded into production prior to the effective dates.
• Ensures that codes (CPT, HCPC, ICD Diagnosis, ICD Procedure) are mapped, tested, documented, and loaded into production annually, prior to the effective date of the coding group and that regulatory updates are completed as required.
• Ensures that pricing software is updated regularly, tested, logged, and functioning properly in production.
• Triages claims system issues; assigns to staff as appropriate.
• Ensures coordination, maintenance and development of various technical processes (such as EDI, check processing, EOB) as they relate to system configuration.
• Facilitates effective inter-departmental communication so that the impact of procedural changes and system enhancements are fully understood by business owners. Prioritizes objectives and tasks, sets intermediate target dates, tracks project completion, and determines most effective methods to accomplish project goals. Provides analyses and reports to business owners at each major milestone.
• Manages the day-to-day activities of the configuration unit including setting deadlines, monitoring progress, keeping staff on schedule, reviewing the status of ongoing work and reporting any issues that may arise to the Director.
• Performs all other duties inherent in a managerial role. Ensures effective staff development, makes recommendations on staff performance, hires, promotions, terminations, and salary actions.
• Participates in special projects and performs other duties as assigned.

Qualifications

Education:

• Bachelor's Degree in Business Administration, Healthcare Administration, related field or the equivalent work experience required
• Master's Degree in Business Administration, Healthcare Administration, related field preferred

Work Experience:

• Minimum of four years managed health care operations experience required
• Experience with health care information system development required
• Experience managing complex projects across departments required
• Effective communication skills, both written and oral, and proficiency in PC software applications (i.e. Microsoft Office) required