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Experience:
Not specified
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Employment Type:
Intern/Co-op
Posted:
3/17/2015
Job Category:
Information Services
Industry:
Health Care & Medicine
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Senior Benefit and Claims Configuration Analyst
Kaiser Permanente | Rancho Cucamonga, California
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Job Description

The Lead Configuration Analyst is responsible for Analysis, Design, Build and Unit Testing of Provider Contracts and Benefits within the ClaimsConnect Platform, to ensure accurate and timely claims payment consistent with the Regional and National artifacts (e.g. contractual arrangement(s) made with the Providers, Employer Groups, etc.). The Lead Configuration Analyst understands the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in ClaimsConnect platform applications to support the accurate and timely payment of claims.
 
  • Essential Functions:
    Provides technical coding and design advice for benefit development in support of product initiatives
  • Provides expert knowledge, impact analysis and recommendations related to configuration design
  • Understands impacts of benefit data/provider contract data on all systems
  • Creates and/or socializes coding definitions for all benefit designs including tools for project governance, tools and templates, protocols, engagement strategy, escalation protocols, decision-making, risk management and contingency planning
  • Develops processes to analyze, design, configure, code and QA detailed benefit designs and provides assistance to all departments on benefit coding issues
  • Ensures correct interpretation and definition of benefits
  • Develops benefit codes and ensures integration with across all product lines
  • Creates and/or manages project plans and timelines to ensure that a given product plan will produce desired results for the targeted market segment
  • Identifies and seeks approval for key actions necessary to remediate all problems/issues and makes recommendations to management on steps to ensure product is delivered on time within specifications
  • May lead, cross-functional teams of personnel on routine and more complicated scope activities that support Product Development agenda, processes, and programs
  • Reviews, creates and incorporates policies and procedures to implement coding best practices and makes recommendations to management on Regional or Program needs to achieve strategic objectives
  • Develops and presents recommendations and findings to departmental management and cross-functional leadership
  • Develops documentation for senior executives and other key stakeholders and communicate all coding changes
  • Collaborates with Benefit Managers to ensure that a comprehensive Project Plan exists for all key benefit initiatives and will coordinate and facilitate all work teams to develop benefit codes
  • Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment
  • Conducts research and resolution of debarred and sanctioned providers  and communicate required system updates to Provider Contracting and Claims Operations.

The Lead Configuration Analyst is responsible for Analysis, Design, Build and Unit Testing of Provider Contracts and Benefits within the ClaimsConnect Platform, to ensure accurate and timely claims payment consistent with the Regional and National artifacts (e.g. contractual arrangement(s) made with the Providers, Employer Groups, etc.). The Lead Configuration Analyst understands the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in ClaimsConnect platform applications to support the accurate and timely payment of claims.
 
  • Essential Functions:
    Provides technical coding and design advice for benefit development in support of product initiatives
  • Provides expert knowledge, impact analysis and recommendations related to configuration design
  • Understands impacts of benefit data/provider contract data on all systems
  • Creates and/or socializes coding definitions for all benefit designs including tools for project governance, tools and templates, protocols, engagement strategy, escalation protocols, decision-making, risk management and contingency planning
  • Develops processes to analyze, design, configure, code and QA detailed benefit designs and provides assistance to all departments on benefit coding issues
  • Ensures correct interpretation and definition of benefits
  • Develops benefit codes and ensures integration with across all product lines
  • Creates and/or manages project plans and timelines to ensure that a given product plan will produce desired results for the targeted market segment
  • Identifies and seeks approval for key actions necessary to remediate all problems/issues and makes recommendations to management on steps to ensure product is delivered on time within specifications
  • May lead, cross-functional teams of personnel on routine and more complicated scope activities that support Product Development agenda, processes, and programs
  • Reviews, creates and incorporates policies and procedures to implement coding best practices and makes recommendations to management on Regional or Program needs to achieve strategic objectives
  • Develops and presents recommendations and findings to departmental management and cross-functional leadership
  • Develops documentation for senior executives and other key stakeholders and communicate all coding changes
  • Collaborates with Benefit Managers to ensure that a comprehensive Project Plan exists for all key benefit initiatives and will coordinate and facilitate all work teams to develop benefit codes
  • Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment
  • Conducts research and resolution of debarred and sanctioned providers  and communicate required system updates to Provider Contracting and Claims Operations.

Qualifications

Basic Qualifications:

  • A minimum of five years of experience in health care or managed care or equivalent education/experience such as in claims adjudication with knowledge of at least one of the following: membership, benefits, provider contracts and pricing, medical reviews, referral authorizations and code review and fee schedule
  • At least three years of experience as configuration analyst
  • Significant experience in documentation, research and reporting
  • Bachelors degree in information systems, business or health care administration, or other related field OR a minimum of four years of experience in a directly related field
  • High school diploma or GED
  • Certification in Tapestry in Core and either AP or Benefits Modules must be obtained within 6 months of hire
  • Demonstrated intermediate competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database
  • Knowledge of state and federal regulations
  • Advanced proficiency in MS Office Suite of products
  • Thorough understanding of relational databases
  • Complete understanding and application of principles, concepts, practices, and standards
  • Advanced knowledge in healthcare benefits, benefit administration and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycle, along with health insurance industry practices and standards
 
Preferred Qualifications:
  • Current certification in other Tapestry modules in addition to Core, AP and Benefits
  • Basic proficiency in Statistical analysis
  • Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, etc.)
  • Knowledge of Kaiser Permanente Internal processes
  • Knowledge of Epic Tapestry Modules

Basic Qualifications:

  • A minimum of five years of experience in health care or managed care or equivalent education/experience such as in claims adjudication with knowledge of at least one of the following: membership, benefits, provider contracts and pricing, medical reviews, referral authorizations and code review and fee schedule
  • At least three years of experience as configuration analyst
  • Significant experience in documentation, research and reporting
  • Bachelors degree in information systems, business or health care administration, or other related field OR a minimum of four years of experience in a directly related field
  • High school diploma or GED
  • Certification in Tapestry in Core and either AP or Benefits Modules must be obtained within 6 months of hire
  • Demonstrated intermediate competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database
  • Knowledge of state and federal regulations
  • Advanced proficiency in MS Office Suite of products
  • Thorough understanding of relational databases
  • Complete understanding and application of principles, concepts, practices, and standards
  • Advanced knowledge in healthcare benefits, benefit administration and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycle, along with health insurance industry practices and standards
 
Preferred Qualifications:
  • Current certification in other Tapestry modules in addition to Core, AP and Benefits
  • Basic proficiency in Statistical analysis
  • Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, etc.)
  • Knowledge of Kaiser Permanente Internal processes
  • Knowledge of Epic Tapestry Modules

About Kaiser Permanente

Company Description

Serving approximately 8.7 million members in nine states and the District of Columbia, Kaiser Permanente is America's leading nonprofit integrated health plan.

Kaiser Permanente's mission is to provide high-quality, affordable health care services to improve the health of our members and the communities we serve.

Our Northern California Region provides integrated health care services to approximately 3.2 million members. Approximately 4,400 physicians of The Permanente Medical Group provide services at 20 medical centers and numerous medical offices.

Company History

Founded in 1945, Kaiser Permanente is the nation’s largest not-for-profit health plan, serving more than 8.6 million members, with headquarters in Oakland, Calif. It comprises:

  1.   • Kaiser Foundation Health Plan, Inc.

  • Kaiser Foundation Hospitals and their subsidiaries

  • The Permanente Medical Groups.

At Kaiser Permanente, physicians are responsible for medical decisions. The Permanente Medical Groups, which provide care for Kaiser Permanente members, continuously develop and refine medical practices to help ensure that care is delivered in the most efficient and effective manner possible.

Kaiser Permanente’s creation resulted from the challenge of providing Americans medical care during the Great Depression and World War II, when most people could not afford to go to a doctor. Among the innovations it has brought to U.S. health care are:

  • prepaid health plans, which spread the cost to make it more affordable

  • physician group practice to maximize their abilities to care for patients

  • a focus on preventing illness as much as on caring for the sick

  • an organized delivery system, putting as many services as possible under one roof

Mission & Values

As a health care organization in the 21st century, we have a mission--to provide quality care for our members and their families, and to contribute to the well-being of our communities.

Working Here

When you bring your career to Kaiser Permanente, the work you do directly affects the health of millions. From the business people who shape our policies, to the IT professionals enabling life-saving data, to the nurses and physicians on the front line of patient care, everyone here has a role to play in the care continuum. Knowing you have a place in that process and witnessing the outcome of the work you do is empowering. It gives you a cause to stand behind. And it makes you feel proud of the work you do every day. When people witness the impact of their contributions, they excel. Together we have the power to make a difference.

Hiring Information

The first step in beginning your career search is to look for open jobs that match your skills, qualifications, and interests. Each posting includes a description of the position and the minimum required qualifications. Once you find a position you are interested in, register for an account and provide your information for consideration online.

Benefits

As an employee, you are eligible for benefits according to your full-time/part-time status and the number of hours scheduled to work per week. Benefits may vary based on your Kaiser Permanente region, position, scheduled hours, and representation by collective bargaining or employee groups, but generally include:

  • generous vacation, holiday, and sick leave

  • medical care (including prescriptions), vision, mental health, and dental care

  • disability and life insurance coverage

  • educational opportunities and tuition reimbursement

  • employee assistance programs

  • health care, dependent care, and transit spending account options

  • retirement plans

In addition, we believe in recognizing stellar performance and sponsor a variety of programs designed to reward our skilled, innovative, caring, and committed staff.

In short, at Kaiser Permanente, we understand that there is a direct correlation between happy employees and happy members. We take pride in the compassion and dedication of our employees and find many ways to reward their hard work. In return, our employees take pride in being a part of a collaborative, professional team focused on quality, service, and care.

Honors & Awards

Kaiser Permanente of Northern California has earned an "Excellent" rating from the National Committee for Quality Assurance (NCQA)-the nation's leading reviewer of health plan quality for consumers and employers. Excellent is the top rating granted by NCQA, which reviews satisfaction surveys, preventive measures, physician credentialing, member services and improvement initiatives.*

Both our Northern and Southern California regions were the only health plans in California identified by the NCQA in its list of the best health care programs in the Pacific States. (NCQA's The State of Health Care Quality 2003)

The Joint Commission on Accreditation of Healthcare Organizations accredits all Kaiser Foundation Hospitals in California.

For the seventh straight year, no other health plan has earned higher ratings from the California Cooperative Health Reporting Initiative on more measures than Kaiser Permanente. The annual ratings measure clinical quality and member satisfaction. (CCHRI Report on Quality 2003)

Our Northern California region received more three-star "Excellent" ratings than any other health plan surveyed by California's Office of the Patient Advocate on California's Quality of Care Report Card 2003-04.

* Commercial HMO and Medicare-contracted product lines: April 2003.