Job Description:
You will be part of a team dedicated to processing configuration for Claims, Benefits, and Pricing for a non-profit Healthcare Organization in the US and will collaborate with Product Owners, Managers, and Developers within India, US and Mexico.
The successful candidate should have a deep understanding of Health Plan Payer operations, provider contract terms and methodologies, claims processing, and configuration experience with a health plan core claims processing platform.
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Detailed knowledge of Client HealthRules software (Product of HealthEdge) required.The ideal candidate should have excellent oral and written communication skills and the ability to interface with all levels of the customer organization. This experience should have come from a combination of health plan, software vendor, systems integrator, or consulting organization.
Responsibilities
- Create new and modify existing Claims Pricing configurations. Configures and maintains the business rules within the Claims Processing ecosystem.
- Configures the HealthRules (benefits and Package pricing) software from development into the testing and deploying to the production environment.
- Recommends and implements benefit and pricing setup based on knowledge of system configuration capabilities and information obtained from business clients. Independently evaluates business procedures and problems.
- Hands-on working knowledge in resolving production issues related to Benefit configurations.
- Identifies research and resolves inaccuracies and inconsistencies in the business rules as they impact claims payment and other upstream and downstream transactions.
- Resolve configuration defects and perform testing to validate the updates are working as expected.
- Participates in business requirements gathering sessions to identify specifications and solutions.
- Evaluate and recommend configuration solutions to Business and IT leadership. Identifies and assesses potential problems and performs and implements system enhancements, modifications, and upgrades.
- Provides application and technical support for the HealthRules software as well as troubleshooting for end users. Works with IT to define business and IT systems requirements.
- Identifies and assesses potential problems and performs and implements system enhancements, modifications, and upgrades.
- Mentors and guides business users with the design and impact of configuration changes.
- Creates test case scenarios for application and configuration testing and ensures appropriate testing has been completed before the changes are deployed into the production environment.
- Designs, develops, and maintains user system documentation. Evaluates and monitor coded data elements. Assists users in understanding business system functions.
Mandatory Skills Description:
- 4+ years of HealthCare operations or Healthcare claims processing experience. Working experience with HRP (HealthRules Payor) application i.e., Designer and Manager.
- Experience Training others on the technical aspects of HE/HRP system migrations. U
- nderstand Healthcare Eligibility and Claims data flow in HealthRules. Proficiency in Healthcare and Health Plan terminology, and medical coding (e.g., CPT, HCPCS, ICD9 & ICD10 CDT, Revenue, DRG, and other relevant medical and industry-standard codes).
- Deep understanding of benefit plans, benefits association (package, coverage, component, and detail), benefit coding (Benefit keywords and linkage associations),
- Claims to process, and workflows for multiple Lines of Business including FEP, and BCBS Association mandates. Strong experience in SQL and other relevant tools and technology used for Benefit configuration updates.
Nice-to-Have Skills:
Working knowledge of MS Azure DevOps. Experience in Agile methodology and framework. Certified Health Rules Payer for Business/Function roles.
Education:
Bachelor's degree in Business Administration, Management Information Systems, Computer Science, or equivalent work experience. In lieu of a degree, a minimum of 3-4 years of proven configuration experience, preferably on Facets, HealthRules, Diamond, Amisys Advance, or a similar payer system.
