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Experience:
1-3 years of experience
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Employment Type:
Intern/Co-op
Posted:
4/9/2015
Job Category:
Information Services
Industry:
Health Care & Medicine
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Benefits and Claims Configuration Analyst
Kaiser Permanente | Rancho Cucamonga, California
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Job Description

 

The HPSC Configuration Analyst (CA) is responsible for Analysis, Design, Build and Unit Testing of Provider Contracts and Benefits within the KPCC 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 HPSC Configuration Analyst understands the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in KPCC platform applications to support the accurate and timely payment of claims.  Uses Configuration Design templates to create and maintain artifacts (e.g. Build Worksheets to be used as documentation / specifications for Certification or National Testing Teams). Consults appropriate internal partners on issues of interpretation/clarity.   Performs other duties as assigned by Management.

  

Essential Functions:
Includes all responsibilities of the Intermediate Configuration Analyst and Configures Either: Professional & Institutional Providers or Complex Benefits.
  Leads business requirements development and solution design process including creation of requirements and design documentation and facilitating sessions with business owners and other team members).
Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment.
Coordinates, researches and resolves debarred and sanctioned provider data  and ensures communication of required system updates to Provider Contracting and Claims Operations.
Conducts preliminary evaluation of contractual agreement  prior to execution to determine system configurability. 
Conducts systems requirement assessment in support of regulatory changes (e.g. ICD-10, ASC, DRG etc.).
Analyzes business requirements to determine the best approach for configuration design, testing and implementation.
Analyzes benefit evidence of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums  and state/regulatory benefits coverage.
Develops, documents and executes test plans for configuration testing and validates accuracy of data loaded.
Acts as the liaison between business configuration and business owners to ensure that all application and technical-oriented issues relating to the configuration requests/projects are appropriately addressed.
Writes/generates ad-hoc claims impact reports and compiles reconciliation  statements. 
Tests new version releases relative to system configuration and documents results.
Analyzes and make recommendations to management regarding system enhancements and communicates system problems and impact on operations.
Acts as the subject matter expert regarding Configuration Activities for cross-regional/national initiatives. Assists in establishing, and documenting policies and procedures in support of standardized and accurate configuration. 
Validates design, testing and implementation of Configuration.
Provides coaching and mentoring to team members, workload distribution, tracking and workflow management.
Travels for team meetings up 25% of the time.

 

The HPSC Configuration Analyst (CA) is responsible for Analysis, Design, Build and Unit Testing of Provider Contracts and Benefits within the KPCC 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 HPSC Configuration Analyst understands the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in KPCC platform applications to support the accurate and timely payment of claims.  Uses Configuration Design templates to create and maintain artifacts (e.g. Build Worksheets to be used as documentation / specifications for Certification or National Testing Teams). Consults appropriate internal partners on issues of interpretation/clarity.   Performs other duties as assigned by Management.

  

Essential Functions:
Includes all responsibilities of the Intermediate Configuration Analyst and Configures Either: Professional & Institutional Providers or Complex Benefits.
  Leads business requirements development and solution design process including creation of requirements and design documentation and facilitating sessions with business owners and other team members).
Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment.
Coordinates, researches and resolves debarred and sanctioned provider data  and ensures communication of required system updates to Provider Contracting and Claims Operations.
Conducts preliminary evaluation of contractual agreement  prior to execution to determine system configurability. 
Conducts systems requirement assessment in support of regulatory changes (e.g. ICD-10, ASC, DRG etc.).
Analyzes business requirements to determine the best approach for configuration design, testing and implementation.
Analyzes benefit evidence of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums  and state/regulatory benefits coverage.
Develops, documents and executes test plans for configuration testing and validates accuracy of data loaded.
Acts as the liaison between business configuration and business owners to ensure that all application and technical-oriented issues relating to the configuration requests/projects are appropriately addressed.
Writes/generates ad-hoc claims impact reports and compiles reconciliation  statements. 
Tests new version releases relative to system configuration and documents results.
Analyzes and make recommendations to management regarding system enhancements and communicates system problems and impact on operations.
Acts as the subject matter expert regarding Configuration Activities for cross-regional/national initiatives. Assists in establishing, and documenting policies and procedures in support of standardized and accurate configuration. 
Validates design, testing and implementation of Configuration.
Provides coaching and mentoring to team members, workload distribution, tracking and workflow management.
Travels for team meetings up 25% of the time.

Qualifications

Basic Qualifications:
Experience
Minimum three (3) years of experience in a health insurance or managed care environment or equivalent education / experience such as in claims adjudication with knowledge of at least one of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules.
Strong experience in documentation, research and reporting.
Education
Bachelors degree in business, health care or other applicable field OR a minimum four (4) years of experience in a directly related field.
License, Certification, Registration

Certification in at least one (1) Tapestry Module (e.g. Core , AP, Benefits) within six (6) months of hire.
 
Additional Requirements:
Proficiency in Healthcare and Health Plan  terminology, medical coding (e.g. CPT4, ICD9, and HCPCS), provider contract concepts and common claims adjudication practices and General Health plan functions.
Intermediate knowledge MS Office Suite of products.
Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related deliverables.
Understand relational databases.
Strong analytical and problem solving skills.
Excellent interpersonal, communication, & listening skills.
Proficiency 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.
Understands needs of claims clients and relationships.

 

Preferred Qualifications:
Certification in more than one Tapestry preferred.
Knowledgeable of state and federal regulations preferred.
Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, etc.) preferred.
Knowledge of Kaiser Permanente Internal processes preferred.
Knowledge of Epic Tapestry Modules preferred.

Basic Qualifications:
Experience
Minimum three (3) years of experience in a health insurance or managed care environment or equivalent education / experience such as in claims adjudication with knowledge of at least one of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules.
Strong experience in documentation, research and reporting.
Education
Bachelors degree in business, health care or other applicable field OR a minimum four (4) years of experience in a directly related field.
License, Certification, Registration

Certification in at least one (1) Tapestry Module (e.g. Core , AP, Benefits) within six (6) months of hire.
 
Additional Requirements:
Proficiency in Healthcare and Health Plan  terminology, medical coding (e.g. CPT4, ICD9, and HCPCS), provider contract concepts and common claims adjudication practices and General Health plan functions.
Intermediate knowledge MS Office Suite of products.
Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related deliverables.
Understand relational databases.
Strong analytical and problem solving skills.
Excellent interpersonal, communication, & listening skills.
Proficiency 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.
Understands needs of claims clients and relationships.

 

Preferred Qualifications:
Certification in more than one Tapestry preferred.
Knowledgeable of state and federal regulations preferred.
Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, etc.) preferred.
Knowledge of Kaiser Permanente Internal processes preferred.
Knowledge of Epic Tapestry Modules preferred.

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.