The Contract Configuration Analyst is responsible for translating standard, complex, and varied business needs into the organization's configuration rules. To be successful, one must possess the technical expertise of the required operational phases of the business systems and analysis skills to translate the information accurately. Business acumen is essential to fully understand the implications of the configuration role on other interrelated businesses related to benefits and provider contracts.

The configuration work impacts the end result of the organization's health plans as well as the quality of claims operations, customer care operations, and cost containment & recovery operations. With a strong dedication to excellent work, quality ensures that our members and providers have a positive experience as part of the Fallon Health network and that we pay claims correctly and on time, avoiding fines and extra costs.

The Contract configuration team is responsible for ensuring that claims are paid correctly based upon the contract configuration, medical policies, reimbursement policies, claims editing policies, EOHHS, and CMS requirements.

Job Responsibilities:

• Performs configuration based upon varying reimbursement methodologies such as APR-DRG, MS-DRG, OPPS, APC Grouper, RBRVS, and Pharmacy
• Maintains detailed knowledge of hospital, ancillary and professional billing, including CPT, HCPS, DRG, and Ambulatory Surgery Coding
• Researches and stays current with changes in CMS Medicare and Medicaid reimbursement models.
• Advances best practices in documentation, data quality, and data management
• Adheres to contract quality metrics
• Participates in any audits (CMS, Internal, etc.) and provides remediation responses in short order when necessary
• Executes accurate fee for service and value-based contracting configuration
• Supports the development and execution of ad-hoc data requests needed to support various business needs
• Ensures SOC and Model Audit Controls (MAR) are designed and functioning appropriately
• Develops and keeps current existing Policies and Procedures
• Completes all edits and call tracking cases are completed within applicable SLA
• Analyzes code publications in addition to new or updated policies to assess and respond to impact on the configuration and related processes
• Explores process improvement opportunities as well as mentors new and current team members
• Expedites implementation delays and escalates issues to management as appropriate
• Serves as the subject matter expert as it relates to configuration tasks and manages issues to a positive outcome
• Actively participates and facilitates as needed in meetings related to contract configuration
• Develops and executes test plans as is relates to core system upgrades such as QNXT or Symplir
• Maintains current knowledge of pricing applications and code editing software
• Executes upon all business goals with quality and effectiveness
• Maintains thorough and concise documentation for tracking
• Assists with the development of configuration standards and best practices
• Handles fluctuating volumes of work and prioritizes work to meet deadlines and business needs independently
• Escalates identified issues, makes recommendations, and implements configuration changes to improve the accuracy and efficiency of processes
• Works independently with the Network Development team to understand and implement contract requirements
• Maintains current knowledge of industry-standard code sets and government regulations as mandated by the regulatory agencies such as NCQA, CMS, NPI, etc.
• Other duties as assigned

Requirements:

Education:

• Bachelor’s Degree in business or equivalent business work experience

Experience:

• Minimum 4-7 years I am working in the Healthcare industry with detailed provider contract configuration knowledge on Regulatory products such as Medicaid, Medicare, Duals, PACE, etc.
• 3-7 years of experience with QNXT or a similar database is required in Healthcare Administration
• Systems thinking – must understand systems/people and the impact of business changes particularly as they affect internal and external business partners.
• Strong communication skills (formal and informal, written and verbal)
• Ability to handle multiple demands - must be able to balance multiple priorities (i.e., contract configuration, working edits, etc.)
• Quick learner who can act as an advocate
• Proficient in Microsoft product suite (i.e., Word, Excel, PowerPoint, etc.)
• Highly organized problem solver with understanding of system capabilities and business needs; deep knowledge of systems at hand
• Prior experience working with and responding to customer service cases, claims administration, enrollment or appeals, and grievances related to inaccurate configuration information.

Years of Experience: 3 years

Job Type: Full-time

Pay: $70,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Experience level:

• 3 years

Schedule:

• 8 hour shift
• Monday to Friday

Education:

• Bachelor's (Required)

Experience:

• customer service claims: 4 years (Required)
• QNXT or similar data bases: 3 years (Required)
• Healthcare industry: 4 years (Required)

Work Location: Hybrid remote in Worcester, MA 01608

Please Note :
www.bankofmontserrat.ms is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, www.bankofmontserrat.ms provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.