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Role: Claims Analyst / Claims test analyst
Location: Hopewell NJ
Duration: 6 Months
The Configuration Analyst II is responsible for gathering requirements from internal and external clients, providing business and technical expertise in support of the business area. The Configuration Analyst II will provide configuration expertise during the design/build sessions to find the most appropriate solution as well as ensure the proposed solutions support and enhance business operations. Specifically, the Configuration Analyst II elicits, analyzes, performs preliminary testing, communicates and validates requirements for changes to business processes, policies and transaction processing system by creating Functional and Configuration documentation including development, technical and implementation. This person is responsible for ensuring that all tasks are completed in a timely and accurate manner including receiving proper approvals through all control boards. This person works at a senior level of activity and work process coordination and functions independently within authorized limits.
May partner with external areas to coordinate work and ensure that deliverables are met and that guidelines/policies are followed -
1. Identifies pricing and configuration issues and recommends solutions to solve gaps between external expectations and system limitations, suggesting configuration improvements or streamlined maintenance processes. Initiates error correction and claim re-adjudication related to fee schedule, contract configuration, and other file discrepancies.
2. Develops test plans and completes file, data, and logic validation while performing user acceptance testing for updates instituted by Trizetto. Performs post-implementation validation of all related changes moved into the production environment.
3. Serves as department subject matter expert (SME) while attending sessions on benefits reimbursement, policy development, configuration, and other committees/meetings with business owners and assist with the development of complete business requirements for configuration projects.
4 Assists with the development of Business Configuration Analysts job aids, training materials, reference guides, and other documentation. Train other Analysts/Consultants/Temps as needed for assistance on assigned projects.
5. Analyzes complex provider contracts and design/configure provider agreements, including validation of configuration and peer review.
6. Assists manager in prioritizing unit activities identifying those items which are critical to client's business operations as highest priority.
7. Researches and resolves audit related inquiries, determines root cause of payment discrepancies, and reports all findings to Manager.
8. Updates and maintains key inventory logs for management review to assist with inventory controls and quality audits.
9. Assists vendor with the configuration of edits, CPT/HCPCS & ICD10 procedure and diagnosis codes, place and service code mapping annually or as required for accurate claims processing.
1. Requires Bachelor's Degree.
2. Requires a minimum of 5 years of experience with claims processing (FACETS Applications preferred)
3. Requires a minimum of 3 years of experience translating business requirements into detailed system specifications.
4. Thorough knowledge of medical terminology, surgical procedures, CPT/HCPCS, and ICD coding methodologies.
5. Must know SQL
1. Working knowledge of process for updating and development of new policies and integration of the same.
2. Working knowledge of Windows operating system and its utilities.
3. Ability to provide analysis, problem solving, and interpret application configuration.
Skills and Abilities:
1. Requires strong organizational and analytical skills
2. Requires excellent oral and written communication skills.
3. Requires MS Office and technical system skills.
4. Requires the ability to work with all levels of personnel.
5. Clearly articulate (both verbal and written) project status and issues management.
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