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Experience:
1-3 years of experience
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Employment Type:
Intern/Co-op
Posted:
4/16/2015
Job Category:
Information Services
Industry:
Health Care & Medicine
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Configuration Analyst II
Kaiser Permanente | Rancho Cucamonga, California
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Job Description

The position will understand the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in the existing application (the host processing system), & other platform applications to support the accurate & timely payment of claims for the Regions' Claims systems. Tests new releases, makes recommendations on system enhancements, & evaluates contracts for configuration which includes system capabilities. Consults w/ approp internal partners on issues of interpretation. Works w/ the Product Mgrs & Developers to define, code, configure & maintain detailed provider/benefit services & provider/benefit plans designs for the applications that require benefit info. Helps to bring products to market that meet customer needs & expectations & ensures that product & operational goals are achieved. Makes sure benefits are well defined & can be configured in all applications that require benefit data / provider contract data. Provides consultation & support to all other employees responsible for configuring benefits into KP benefit systems. Also ensures that the benefit coding definitions are consistent across the organization. Provide subject matter expertise throughout the organization for benefit coding, billing & benefit configuration & ensure consistency & compliance of benefit coding definitions across applications. The position clearly understands the products & healthcare benefit services offered to our customers, including cost share, limits, accumulators, & regulatory rules & guidelines. The position's function will leverage applicable components of the Product Development Mgmt Process (PDMP) or similar processes & Comprehensive Delivery Process (CDP) or similar processes to bring KP products to the market.
 
Essential Functions:
Performs configuration activities (which may include at least one of the following: Institutional & Provider Contracts, Benefits Authorizations, and/or General Configuration such as System Edit Rules, Fee Schedules updates, etc.) in Diamond Claims Processing system or other system resulting in 100% claim payments consistent w/ the contractual arrangement(s) made w/ the Provider, & according to the Groups Evidence of Coverage
Ensures the provider, authorization & benefits configuration meets estd. business rules & procedures
Modifies the provider contract, authorization rules & benefit plan configuration as req'd
Loads new contracts/ authorization/ benefit configuration into Diamond
Uses MACESS workflow to monitor contract updates & contract(s) matrix/grid
Consults w/ relevant Contract Mgr or business analyst to determine approp interpretation & configuration of contract terms
Maintains detailed knowledge & understanding of Diamond rules relative to claims payment
Analyzes provider contracts to determine the best approach for loading data elements into the claim processing system
Analyzes benefit explanation of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums & state/regulatory benefits
Analyzes medical mgmt requirement to determine best approach for loading authorization rules into the claims processing system
Develops, documents & executes test plans for configuration testing & validate accuracy of data loaded
Coordinates research & resolution of debarred & sanctioned providers & ensures communication of req'd system updates to Provider Contracting & Claims Ops
Assume other duties as directed
 
The position will understand the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in the existing application (the host processing system), & other platform applications to support the accurate & timely payment of claims for the Regions' Claims systems. Tests new releases, makes recommendations on system enhancements, & evaluates contracts for configuration which includes system capabilities. Consults w/ approp internal partners on issues of interpretation. Works w/ the Product Mgrs & Developers to define, code, configure & maintain detailed provider/benefit services & provider/benefit plans designs for the applications that require benefit info. Helps to bring products to market that meet customer needs & expectations & ensures that product & operational goals are achieved. Makes sure benefits are well defined & can be configured in all applications that require benefit data / provider contract data. Provides consultation & support to all other employees responsible for configuring benefits into KP benefit systems. Also ensures that the benefit coding definitions are consistent across the organization. Provide subject matter expertise throughout the organization for benefit coding, billing & benefit configuration & ensure consistency & compliance of benefit coding definitions across applications. The position clearly understands the products & healthcare benefit services offered to our customers, including cost share, limits, accumulators, & regulatory rules & guidelines. The position's function will leverage applicable components of the Product Development Mgmt Process (PDMP) or similar processes & Comprehensive Delivery Process (CDP) or similar processes to bring KP products to the market.
 
Essential Functions:
Performs configuration activities (which may include at least one of the following: Institutional & Provider Contracts, Benefits Authorizations, and/or General Configuration such as System Edit Rules, Fee Schedules updates, etc.) in Diamond Claims Processing system or other system resulting in 100% claim payments consistent w/ the contractual arrangement(s) made w/ the Provider, & according to the Groups Evidence of Coverage
Ensures the provider, authorization & benefits configuration meets estd. business rules & procedures
Modifies the provider contract, authorization rules & benefit plan configuration as req'd
Loads new contracts/ authorization/ benefit configuration into Diamond
Uses MACESS workflow to monitor contract updates & contract(s) matrix/grid
Consults w/ relevant Contract Mgr or business analyst to determine approp interpretation & configuration of contract terms
Maintains detailed knowledge & understanding of Diamond rules relative to claims payment
Analyzes provider contracts to determine the best approach for loading data elements into the claim processing system
Analyzes benefit explanation of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums & state/regulatory benefits
Analyzes medical mgmt requirement to determine best approach for loading authorization rules into the claims processing system
Develops, documents & executes test plans for configuration testing & validate accuracy of data loaded
Coordinates research & resolution of debarred & sanctioned providers & ensures communication of req'd system updates to Provider Contracting & Claims Ops
Assume other duties as directed
 

Qualifications

Basic Qualifications:
Three (3) to five (5) years of experience in health insurance or managed care environment
Three (3) to five (5) years of experience in claims adjudication with an in-depth knowledge of at least two of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules
Three (3) to five (5) years of experience in system design and analysis (provider contract or benefits administration), preferred
Two (2) - three (3) years of experience on the host claims processing system, preferred
Experience interpreting and relaying Kaiser Permanente Health Plan benefits and services, preferred
Experience in systems testing or user acceptance testing, preferred
Bachelor's degree in business, health care or other applicable field or equivalent experience
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 experience in documentation, research and reporting
Strong analytical and problem solving skills
Excellent interpersonal, communication, & listening skills
Proficiency in medical terminology, medical coding (CPT4, ICD9, and HCPCS), provider contract concepts and common claims adjudication practices
Intermediate proficiency in Excel
Knowledgeable of state and federal regulations
Beginner's proficiency in Access and Query tools
Understands needs of claims clients and relationships
Basic Qualifications:
Three (3) to five (5) years of experience in health insurance or managed care environment
Three (3) to five (5) years of experience in claims adjudication with an in-depth knowledge of at least two of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules
Three (3) to five (5) years of experience in system design and analysis (provider contract or benefits administration), preferred
Two (2) - three (3) years of experience on the host claims processing system, preferred
Experience interpreting and relaying Kaiser Permanente Health Plan benefits and services, preferred
Experience in systems testing or user acceptance testing, preferred
Bachelor's degree in business, health care or other applicable field or equivalent experience
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 experience in documentation, research and reporting
Strong analytical and problem solving skills
Excellent interpersonal, communication, & listening skills
Proficiency in medical terminology, medical coding (CPT4, ICD9, and HCPCS), provider contract concepts and common claims adjudication practices
Intermediate proficiency in Excel
Knowledgeable of state and federal regulations
Beginner's proficiency in Access and Query tools
Understands needs of claims clients and relationships

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.