Configuration & Coding Analyst I
POSITION SUMMARY
The Configuration & Coding Analyst I will assist with the identification and implementation of solutions which result in the efficient, accurate, and quality configuration and maintenance of Community Health Options claim adjudication platform. The Configuration & Coding Analyst consults with assigned operational areas to support operations-identified requirements and ensures timely configuration and implementation of selected solutions either by directly configuring the solution or providing specifications and/or instructions for configuration of the solution.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
- Lead the development of business requirements, and solution design process when implementing new products
- Supports the Configuration Team and all aspects of the benefit configuration process
- Analyzes new business requirements for benefit design changes to establish the appropriate solution
- Assists with auditing, troubleshooting, and resolving claim adjudication issues relating to system configuration
- Ensure compliance with member benefit regulations across all product lines
- Supports the maintenance of the code editing software, and/or vendor solution
- Assists with system testing (including patches, upgrades, and new configuration)
- Validates system configuration revisions in concert with BPO partner
- Configures and/or supports configuration of other related applications, as assigned
- Accurately and reliably maintains, documents and tests configuration
- Analyzes existing and proposed business requirements prior to implementation, and reports results to department and organization management
- Documents and maintains system configuration workflows
- Diagnoses and resolves system configuration issues and defects in coordination with Benefits Analyst
- Acts as liaison with operations, (i.e., IT, Claims, Provider Relations and Finance, Medical Management)
- Collaborates with other departments to define business requirements associated code level data to plan benefits
- Assists with translating benefits into system configuration parameters
- Ensures compliance with the health plan policies for complete, accurate and consistent benefit plan design, resulting in appropriate benefit administration and data integrity
- Reviews and revises business and plan design requirements for system set-ups and configuration
- Communicates identified issues and opportunities for improvement regarding the system enhancements
- Compiles information and prepares reports representing analysis of the results of benefit configuration defect and/or adverse findings, and recommends solutions or resolution pathways
- Collaborates closely with BPO partner, clearly communicates system configuration needs, guides development, testing, validation, and defect resolution via Salesforce ticketing system
- Other projects as assigned
JOB SPECIFIC KEY COMPETENCIES (KSAs)
- Experienced in benefit solution design and configuring
- Proficiencies: Advanced coding skills and knowledge; understanding of professional, outpatient and/or inpatient billing requirements, DRG methodology, as well as knowledge of the AHA and NCCI coding,
- Specialized Knowledge: knowledge of ICD-109-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic and relevant CMS regulations
- Working knowledge of CPT, HCPCs and ICD-CM Codes
- Effective communication skills (verbal and written), ability to serve as a resource and mentor regarding coding and compliance issues.
- Strong knowledge of medical benefits administration and other healthcare concepts
- Ability to independently research and problem solve
- Attention to detail and accuracy
- Proven analytical experience
- Proficiency in the Microsoft Office Suite
- Strong relationship-building skills
DIVERSITY, EQUITY, AND INCLUSION STATEMENT
Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:
- Respectful, open communication and cooperation between all employees.
- Teamwork and participation, encouraging the representation of all groups and employee perspectives.
- Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
- Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.
QUALIFICATIONS AND CORE REQUIREMENTS
- Bachelor's degree, or a combination of related work experience and education
- Five or more years of Health Plan Experience
- Three or more years of experience in a healthcare plan and/or claims processing environment, direct configuration experience
- CPC (Certified Professional Coder), CHC (Certified Hospital Coder) and/or CIH (Certified Inpatient Coder) certification desired
