Job Description

JOB SUMMARY:

The EBMS Configuration Specialist II is responsible for analysis, design, build and unit testing of moderate to complex benefit plans within the Javelina platform to ensure accurate and timely claims payment consistent with the contractual arrangements made with Providers, Employer Groups, etc. The position is responsible for developing an extensive expertise in the core claims adjudication system and all interface applications, both customized and packaged. This position is responsible for coordinating and maintaining assigned systems and analyzes business requirements and objectives towards determining the optimal configuration of requirements.

The Configuration Specialist II may be the primary contact for one or more claims system interface applications and is expected to provide a high level of expertise with matters relating to this interface and its functionality.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

SYSTEM CONFIGURATION

• Configure claims systems to support complex business operations such as benefit plans, authorization requirements, service limits, adjudication logic, dental logic, enrollment configuration and data validation.
• Provides technical coding and design of health care benefit plans. Proficient at utilizing a variety of resources including but not limited to on-line information, files, databases, Medicare/other plan guidelines, plan documents, provider contracts, etc.
• Provides expert knowledge, impact analysis and recommendations related to configuration design.
• Develops processes to analyze, design, configure, code and QA detailed benefit designs.
• Conducts preliminary evaluation of plan document prior to execution to determine best approach for loading benefit offerings including co-pays, out-of-pocket maximums and state/regulatory benefits. Confirms correct interpretation and definition of benefits ensuring integration across all systems.
• Identifies and seeks approval for key actions necessary to remediate all issues and makes recommendations with action steps necessary to deliver on time and within specifications.
• Reviews, creates and incorporates policies and procedures to implement coding best practices and makes recommendations to management on configuration needs to achieve strategic objectives.
• 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.
• Develops, documents and executes test plans for configuration testing and validates accuracy of data loaded.
• Acts as a liaison between business configuration and business owners to ensure that all application and technical-oriented issues relating to the configuration requests are appropriately addressed.
• Tests new version releases relative to system configuration and documents results.
• Acts as the subject matter expert regarding configuration activities for cross-departmental initiatives. Assists in establishing and documenting policies and procedures in support of standardized and accurate configuration.
• Contributes to SRO (Service Recovery Opportunity) process by completing root cause analysis of configuration related incidents, identifies gaps, develops and implements changes in policies and procedures.
• Works with multiple departments to implement complex guidelines, laws or policies from various sources including CMS, DOL, and other sources.

CUSTOMER SERVICE

• Receives and resolves complex internal inquiries regarding customer configuration and set-up.
• Provides timely and thorough follow up with internal and external customers.
• Appropriately escalates difficult issues up the chain of command.
• Acts as a role model in demonstrating the core values in customer service delivery. Excellence, Passion, Innovation, Integrity and Commitment.
• Trains and mentors new employees as assigned.

QUALITY ASSURANCE

• Ability to ensure superior accuracy/quality in deliverables that result in minimal adverse business impact.
• Performs self-quality monitoring in order to ensure customer configuration is 100% accurate across all systems.
• Provides ongoing feedback through peer reviews to help optimize quality performance.
• Develops, documents and executes test plans for configuration testing and validates accuracy of data.
• May lead cross-functional teams of personnel on routine and more complicated scope activities that support product development agenda, processes and programs. Travel is required for applicable meetings when team member works off-site.
• This job description in no way states or implies that these are the only duties to be performed by this employee. The employee will be required to follow any other instructions and to perform any other duties requested by his/her supervisor.

MINIMUM QUALIFICATIONS:

• High school diploma or equivalent
• Bachelor's degree or a minimum of five years of experience in health care with knowledge of membership, benefits, provider contracts, medical review, authorizations or code review.
• A minimum of three years of healthcare claims system configuration.
• Proficiency in healthcare benefits, benefit administration and health care delivery from a payor perspective, EDI and paper claim lifecycle, along with health insurance industry practices and standards.
• Intermediate competency in medical coding, medical terminology, ICD-9/10, CPT and HCPCS.
• Ability to make recommendations and decisions independently.
• Working knowledge of computers and software including but not limited to Microsoft Office products
• Knowledge of relational databases.
• Proficient mathematical, 10-key and typing skills
• Demonstrated analytical skills, organizational skills, problem-solving, and detail oriented
• Demonstrated ability to remain neutral and maintain confidentiality
• Strong written and oral communication skills
• Demonstrated ability to work independently, prioritize workloads multi-task and manage priorities in order to meet deadlines
• Travel for training and team meetings as needed.

PREFERRED QUALIFICATIONS:

• Familiarity with Eldorado Health Pac or Javelina claims processing systems preferred.
• Knowledge of group benefit plans in the self-funded market.
• Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, CAQH CORE, etc.)

Physical Demands & Working Conditions: Work is indoors in an office environment with moderate noise. Intermittent physical effort involving lifting of up to 25 pounds, walking, and stooping, kneeling, crouching, or crawling is required. A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time. Approximately 30% or less of the time is spent standing. Normal vision abilities required, including close vision and ability to adjust focus.

EBMS, LLC is an EEOC Employer

JOB POSTED BY APPLICANTPRO