Sr. Plan Builder and Configuration Analyst at HealthEZ

, , -

Full Time

Start Date

Immediate

Expiry Date

18 Mar, 26

Salary

80000.0

Posted On

18 Dec, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Adjudication, Benefit Configuration, Data Integrity, Process Improvement, Medical Coding, Revenue Codes, Data Analysis, Client Integration, Problem Solving, Communication, Testing, Reporting, User Access Management, Collaboration, Healthcare Reform, CPT Coding

Industry

Insurance

Description

Job Details Salary Range: $70,000.00 - $80,000.00 Salary The Opportunity The Senior Plan Build & Benefit Configuration Analyst is responsible for leading all activities associated with the build, implementation and configuration of benefit plan adjudication rules to ensure the accurate and timely adjudication of claims in accordance with the appropriate plan documents and internal policies and procedures. Responsible for maintaining the data integrity of the claims systems and make adjustments and changes according to system release schedules, enhancements and new and renewing employer groups. The Senior Plan Build & Benefit Configuration Analyst reports directly to the Director, Claims Operations. This position can support a 100% remote work environment. What you’ll do 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 Qualifications What we expect from you 5-10 years of Claims Examiner and/or Plan Build experience 3+ years of business and operations experience in a health plan environment, Must have working knowledge in revenue codes and medical terminology. 2+ years of experience in data analysis Experience with commercial health plan design Professional Medical Coding experience Virtual Benefit Administer (VBA) experience preferred TPA experience preferred Medical coding; ICD-10, CPT, HCPCS certification, highly preferred. High attention to detail Proactive problem-solving skills and communication Ability to multitask and prioritize projects to meet deadlines Reliable and organized Excellent written and verbal communication skills Ability to make sound judgments based on the information available Reporting and analytical skills High School diploma or equivalent We make healthcare EZ! Additional Opportunity Details: Target Base Compensation Range for this role is $70,000-$80,000* * Factors that may be used to determine your actual salary include your job specific skills, education, training, job location, number of years of experience related to this role and comparison to other employees already in this role. Employee benefits are part of the competitive total rewards package that HealthEZ provides to you. Our comprehensive benefits program includes health benefits, retirement plan (401k), paid time away, paid leaves (including paid parental leave) and more. HealthEZ recognizes its responsibilities under federal, state, and local laws requiring non-discriminatory employment practices. All employment decisions, practices and procedures will be carried out without regard to race, color, creed, religion, sex (including pregnancy), sexual orientation, national origin or ancestry, age, marital status, disability, family status, status with regard to public assistance, or any other characteristic protected under applicable local, state, and federal laws. HealthEZ is proud to be an equal opportunity employer.

Responsibilities

The Senior Plan Build & Benefit Configuration Analyst leads the build, implementation, and configuration of benefit plan adjudication rules to ensure accurate claims processing. They maintain data integrity in claims systems and collaborate with internal and external partners on process improvements.