The Sr. Claims Configuration Analyst is responsible for leading and delivering large-scale claims configuration projects across multiple lines of business. This is a highly visible, self-directed position, with exposure to all levels of management that plays a key role in the architecture and configuration of claims business rules. The incumbent of this position is responsible for managing claims configuration projects across functional areas and coaching and indirect management of other Claims Configuration Analysts.
- Lead and deliver projects related to the development and configuration of new business, member benefits and products, claims editing, reference data and their enhancements including claims configuration improvements, compliance and systems enhancements.
- Follow the annual product development processes to manage major claims configuration projects, including claims business rule set up outlier management.
- Interpret specific state and/or federal benefits, contracts as well as additional business requirements and converting these terms to claims configuration set up parameters.
- Translate complex high-level business requirements into functional requirements, specified to an appropriate level of detail.
- Provide expert support to the claims configuration process in addition to providing multifaceted triage and configuration troubleshooting assistance to other Healthfirst business areas.
- Identify and lead the configuration of medical cost savings and automation opportunities through strong analytical skills, process improvement and innovative claims configurations.
- Identify and analyze trends as a result of researching and responding to claims configuration requests, problem reports, and inquiries.
- Identify areas of improvement in existing work processes, and provide guidance.
- Establish claims configuration management policies, procedures and tools. Assist with development of claims configuration standards and best practices.
- Assess overall claims configuration change in scope and undertake work planning for new projects.
- Develop clear, concise documentation that describe claims configuration defect trends so that this information can be used to develop workflow requirements.
- Ensure that business requirements for claims configuration change requests are clearly understood, documented, communicated, tested, and delivered. Maintain claims configuration change documentation to assist other HF operational areas in administering products and benefits.
- Responsible for the quality and integrity of claims configuration change requests through the use of production validation and audit strategies.
- Responsible for organizing release of claims configuration changes to production to reduce the potential for migration conflict.
- Ensure claims configuration test scripts and audit tools, including regression testing cases, are appropriate to validate system configuration changes completed. Serve as claims configuration expert in reviewing end-to-end testing results.
- Lead, plan, direct and coordinate activities of others (non-direct reports) to meet claims configuration deadlines.
- Develop and maintain project timelines, meeting notes, issues resolution documentation, and develop vehicles of communication of this information throughout HF, and externally when appropriate.
- Develop and deliver claims configuration progress reports, proposals, requirements documentation and presentations to Senior Management as needed.
- Additional duties as assigned.
- Associate’s degree from an accredited institution or equivalent work experience.
- Supervisory or leadership experience where the bulk of your duties consisted of coaching, mentoring and training up to 5 employees at a time.
- Experience working with and leading cross-functional and level team members in claims configuration deliverables
- Experience using project tracking, testing and requirement tools (i.e. MS Project, SharePoint or any other time management system).
- Experience with data analysis and query tools that utilize functions that include creating standardized reports, utilizing vLookups, pivot tables, filtering and formulas to generate desired results such as SQl and MS Excel.
- Experience with MS Access functions that include to running queries, Macros and building tables for reporting purposes.
- Experience with PowerMHS or other claims processing systems necessary.
- Comprehensive knowledge of managed care industry and product administration/implementation.
- Proficiency in medical terminology, medical coding (CPT4, ICD9 or ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
- Hands-on experience with, and knowledge of, rules based table driven claims and eligibility administration systems.
- Experience with project tracking, testing and requirements tools.
- Experience creating and delivering presentations using MS PowerPoint and MS Word.
- Bachelor's Degree from an accredited institution.
- Experience working with VBA and Tableau
- Experience troubleshooting and solving claims configuration related issues.
- Experience working within MS Visio and Adobe to create workflow documents and forms.
Compliance & Regulatory Responsibilities: N/A
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
EEO Law Poster and Supplement