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HealthEZ · 1 month ago

Sr. Plan Builder and Configuration Analyst

Bloomington, MN

Full-time

Onsite

Mid, Senior Level

$70K/yr - $80K/yr

5+ years exp

HealthEZ is a company focused on simplifying healthcare processes. The Senior Plan Build & Benefit Configuration Analyst will lead the build, implementation, and configuration of benefit plan adjudication rules, ensuring accurate claim processing and maintaining data integrity within claims systems.

Health CareInsurance

Responsibilities

Execute the build and implementation of benefit plan adjudication rules

Configure benefits and system setup to integrate or convert new clients and/or products as needed, often under aggressive timelines

Responsible for the configuration and data integrity of the claims adjudication system and surrounding vendors and systems to ensure accurate and timely adjudication of claims, adjustments, appeals, IDR’s and High dollar claims

Build and maintain relationships with internal business partners and external vendors

Collaborate with other departments on process improvement projects

Execute application configuration and mapping of client level benefits to align with industry coding (CPT, Place of service, Healthcare Reform, etc)

Evaluate impact of client requested exceptions and develop reasonable alternatives to satisfy client’s needs while minimizing the impact on the application and operations

Represent as the Subject Matter Expert for system configuration and Plan build by reviewing and responding to Opportunity Action Review meetings (OAR’s) as requested and engaging in the weekly SME meetings

Maintain and communicate list of exceptions to client level mapping, benefit standards, coding standards and process exceptions

Collaborate on the review, analysis, and development of recommendations for the design of complex account and benefit structures based on customers’ requirements

Document internal policies and procedures, train on requirements, and monitor compliance with policies and procedures

Create and maintain standard protocols and best practices for: Plan names and plan types assigned to each group, Benefit parameters for benefits and exclusions based on executed plan documents, Network codes, benefit codes, exception codes, and message codes in the claims processing system, Claim routing rules and auditing, and Procedure codes and place of service codes used to adjudicate claims through the claims processing application. ExCode lists and mapping

Create and maintain robust testing examples that are representative of all coverage to better quantify the impact of introducing configuration changes

Test benefit configurations prior to claim adjudication and maintain a current test environment

Track and report key performance metrics and provide reporting to leadership. Perform analysis to determine reasons when actual performance is different than expected and make the necessary corrections

Solicit and assess feedback to enhance continuous quality improvement on the plan build and benefit configuration processes (i.e., Tools, resources, training, etc.)

Participate and make recommendations to improve and streamline systems, processes and manual processing to improve auto adjudication and to create capacity and efficiencies with the claims team

Assess, track and communicate VBA system enhancements, requests and communicate changes to the impacted and appropriate teams

Create and maintain user roles and privileges in the claims processing application. Perform a Bi-Annual review of user access and roles to ensure alignment with user responsibilities

Analyze larger sets claims data to evaluate patterns of billing as it relates to benefit design and configuration

Partner with claim processors and Member experience team to identify and resolve issues related to the plan configuration

Other duties as assigned

Qualification

Claims Examiner experiencePlan Build experienceData analysisMedical codingRevenue codes knowledgeCommercial health plan designProactive problem-solvingMultitaskingCommunicationAttention to detailOrganizational skillsReporting skills