MSO System Configuration Analyst

The MSO System Configuration Analyst is responsible for the major managed care systems configurations, including EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, health plan implementations and conversions within the System Configuration team.

The primary responsibilities include the accurate interpretation of specific state and/or federal guidelines that impact Medicare and/or Medi-Cal benefits, NEMS risk contracts, codification, and business requirements and converting them into configuration parameters within the core systems. Identify regular fee schedule updates as published by CMS and DHCS and transform into system configuration scheme. Monitor monthly encounter data and report submissions to contracted Plans, DHCS, and CMS;

review correspondence and take appropriate follow up actions to accomplish data accuracy and completeness requirements for all managed care programs including PACE, Medicare Advantage and Medi-Cal. Develop reports to monitor system performance and promote integration and automation of systems workflows. Other responsibilities include maintenance of benefit modules, provider profiles set-up (demographic and contracts affiliations), fee schedules, regular coding updates and various system tables through the user interfaces.

The position is also required to produce data reports as demanded by contracted health plans, DHCS, and CMS; reconcile eligibility and capitation data discrepancies between plans and NEMS data; prepare statistic reports to support decision making in managed care business developments. This position will assist in the regular internal review, analysis and audit to all PACE related data issues; identify errors and propose resolutions;

collaborate internally with PACE team and communicate externally with entities including DHCS, CMS, PDAC, Pharma Star, etc. to resolve discrepancies and dissimilarities. This position requires significant level of critical thinking skills, current technical knowledge of MSO operations, processes, workflows, and understanding to the managed care operational structure, coding, benefits, and relevant degree of creativity and latitude.

• Interprets state and federal guidelines that impact managed care system configuration and convert configuration parameters within the MSO core systems, including updates and changes in benefit coverages, fee schedule rates, provider geographic rate adjustments, EDI transmission and date specifications, report submissions and timelines, etc.
• Develops, loads, edits, and maintains EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, and any additional system configuration items; automate system workflows to promote operational efficiency.
• Performs analytical reviews and technical supports for defining, tracking, and resolving issues in the managed care core systems.
• Monitor monthly encounter data and other report submissions to contracted Health Plans, DHCS, and CMS; review correspondence reports and take appropriate follow up actions to accomplish data accuracy and completeness requirements, for all managed care programs including PACE, Medicare Advantage and Medi-Cal.
• Responsible to independently perform regular internal review, analysis and audit to all PACE related data issues; identify errors and propose resolutions; communicate and collaborate internally with PACE team and externally with entities including DHCS, CMS, PDAC, Pharma Star, etc. to resolve discrepancies and dissimilarities.
• Assist in conducting system testing, validation and analyze outputs and results to allow for continuous improvement of the overall QA process for the MSO EZ-Suite system accuracy, integrity, and performance.
• Communicates with other MSO operational teams to understand workflow needs; design, develop and refine Work Queue processes in core managed care systems to strengthen system enhancement activities including data mapping, system integration and workflow automation to meet and improve operation needs.
• Creates and analyzes statistics reports for other operational teams in assist of evaluating business performance links to MSO medical management services.
• Designs training courses and creates training materials to support…