Santa Clara Family Health Plan

along with business contractual agreements impacting benefits, contracts, millions of dollars in claims payment, case management, and/or grievance and appeals within core systems.. Comprehensive understanding and ability to interpret federal and state government (DHCS and CMS) guidelines, and eligibility and enrollment process in order to setup core systems for claims, case management, and grievance and appeals. Combine in-depth analysis of business unit requirements and comprehensive understand of core system capabilities, knowledge of claim processing, provider and vendor setup, authorizations and business processes in order to determine optimal core system setup to process claims, case management, and grievance and appeals with a high degree of accuracy and auto-adjudication.. Serve as a subject matter expert for multiple core systems including but not limited to QNXT, Essette, Beacon, Zipari, NetworX, Optum CES (Claims Editing System), etc.. in order to fix production support issues, or support business needs and regulatory requirements in multiple system applications (such as QNXT, Essette, CES, etc.)

configuration

Salary Range: $104,280 - $161,634
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.
FLSA Status : Exempt
Department: Information Systems
Reports to: Manager, IT Configuration
Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
GENERAL DESCRIPTION OF POSITION
The Configuration Data Analyst is responsible for system configuration, implementations and conversions of SCFHP’s core systems. This position is responsible for the accurate interpretation and associated configuration of regulatory federal and state guidelines. along with business contractual agreements impacting benefits, contracts, millions of dollars in claims payment, case management, and/or grievance and appeals within core systems. The Configuration Data Analyst must have the ability to meet with internal and external business units and peers to gather requirements, independently analyze and mine data, draw sound conclusions, configure, test and implement the data structures that support SCFHP’s managed care information system (s) required to meet business needs, regulatory compliance, and vendor contractual obligations.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
Comprehensive understanding of capitation models in order to setup within our core system to support multiple delegate contracts averaging approximately 50 million dollars in monthly capitation payments, based on accurate setup and configuration.
Comprehensive understanding and ability to interpret simple and complex provider contracts and amendments in order to setup within our core system reimbursement for, but not limited to, hospitals, provider groups, ancillary providers averaging approximately 1 million dollars in weekly claim payments, based on accurate setup and configuration.
Comprehensive understanding and ability to interpret federal and state government (DHCS and CMS) guidelines, and eligibility and enrollment process in order to setup core systems for claims, case management, and grievance and appeals
Combine in-depth analysis of business unit requirements and comprehensive understand of core system capabilities, knowledge of claim processing, provider and vendor setup, authorizations and business processes in order to determine optimal core system setup to process claims, case management, and grievance and appeals with a high degree of accuracy and auto-adjudication.
Serve as a subject matter expert for multiple core systems including but not limited to QNXT, Essette, Beacon, Zipari, NetworX, Optum CES (Claims Editing System), etc.
roubleshoot small to large scale, basic to highly complex business and system production issues by thoroughly reviewing the issue, researching within internal and external documentation such as regulatory publications, and system user guides, performing analysis and critical thinking and testing in order to identify a root cause, document findings, and recommend solutions
Perform basic to highly complex system configuration and maintenance of system rules including but not limited to benefits, authorizations, contracts, fee schedules, DFRs, capitation, letter templates, etc. in order to fix production support issues, or support business needs and regulatory requirements in multiple system applications (such as QNXT, Essette, CES, etc.) for multiple lines of business.
Coordinate the loading, validation, and testing of third party software updates, rate changes, and code changes (CPT, Diagnosis, etc.) with business units and outside vendors, as needed.
Combine in-depth analysis of application configuration and data, information gathered through independent research, knowledge of system capabilities and interdependencies, and business processes to determine the best configuration in order to ensure overall accuracy and efficiency of system processing
Project and task management for small to large scale configuration projects including but not limited to: Attend meetings with business units to gather requirements, track actionable items, send regular communications, escalate identified risks, recommend, implement, and test configuration changes.
Develop documentation of changes, system issues, defects, and bugs including formal requirements, functional specifications, step-by-step configuration setup, root cause, test results reflecting impact to affected business units, manager, and/or external third party vendors.
Perform unit testing and post audit to ensure quality, accuracy, and completeness of work.
Conduct post implementation internal review and analysis in order to refine system rules to further optimize configuration for greater efficiency and accuracy.
Assist in all aspects of new system and new line of business implementations and conversions, as well as core system updates.
Create and maintain basic to moderate SQL based to support business and system processes and initiatives.
Provide training and cross-training to business units on system features and/or new releases.
Mentor and provide training to other configuration analysts or business system analysts on configuration, system features, and/or new releases
Perform other related duties as required or assigned.
REQUIREMENTS – Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
Bachelor’s Degree in Healthcare, Information Systems, or related field, or equivalent experience, training or coursework. (D)
Experience in healthcare (D)
Minimum three years of experience performing the above responsibilities or a minimum of 5 years Claims processing or application vendor experience in a managed care environment. Other additional qualifications may be used to substitute for a required experience. (D)
Ability to work in a group environment and clearly communicate discussion points as needed. (R)
Ability to understand technical requirements and configuration logic to ensure systems are properly configured to meet business needs. (R)
Ability to meet deadlines, multi-task, troubleshoot, and problem-solve. (R)
Must be able to utilize analytical skills to conceptualize and envision impact of changes, and recommend resolutions for business or system issues and gaps. (R)
Ability to audit implemented changes to detect and resolve discrepancies to ensure work is accurate and precise. (R)
General understanding of health care data sets such ICD9/10, CPT/HCPCs, provider contracts and benefits, authorizations, etc. (R)
Knowledge of relational databases such as SQL and Microsoft Access. (D)
Knowledge of CMS and DHCS pricing and benefit structure (D)
Claims processing and Claims Management System configuration experience. (D)
Ability to read and interpret technical procedures, government regulations and guidelines, and various contract provisions, and apply the knowledge. (R)
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R)
Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
Ability to perform the job safely with respect to others, to property, and to individual safety. (R)
Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
Ability to maintain confidentiality. (R)
Ability to comply with SCFHP’s policies and procedures. (R)
Knowledge of project management principles. (R)
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
EOE #J-18808-Ljbffr

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