Sr. Plan Builder and Configuration Analyst

Sr. Plan Builder and Configuration Analyst

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This range is provided by Health

EZ. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$70,000.00/yr - $80,000.00/yr

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.

• 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…