MSO System Configuration Analyst II

The MSO System Configuration Analyst is responsible for the major managed care systems configurations, including EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, other wrap-around applications and health plan implementations and conversions within the System Configuration team. Responsible to perform validation testing to production database post system upgrades and installation of new modules, implementation of hotfixes, etc. which requires after-hour/weekend operation independently without onsite supervision.

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. Strengthen system enhancement activities including data mapping, system integration and workflow automation. Other responsibilities include maintenance of benefit modules, provider profiles set-ups and regular audits (demographic and contracts rates/affiliations), fee schedules, regular coding updates and various system tables through the user interfaces.

This position is responsible to independently perform 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.

The position requires the ability to produce data reports as demanded by contracted health plans, DHCS, and CMS; reconcile eligibility, capitation, claims and authorization data discrepancies between plans and NEMS; prepare statistical reports to support decision making in managed care business developments.

This position requires significant level of critical thinking skills, independent judgment, current technical knowledge and experience of MSO operations and workflow processes.

• Interpret 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 data specifications, report submissions and timelines, etc.
• Develop, transform, edit, and maintain EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, and any additional system configuration framework and substructure; automate system workflows to promote operational efficiency.
• Perform analytical review and technical supports to diagnosis, define, track, and resolve critical 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.
• Perform independent system testing and validation, analyze outputs and results to allow for continuous improvement of the overall QA process for the MSO EZ-Suite system accuracy, integrity, and performance
• Collaborate with other MSO and PACE operational teams to understand workflow needs; design, develop and refine Work Queue processes…