Under the supervision of the Configuration Support Supervisor, the Configuration Support Analyst is responsible for identifying system issues and providing defect resolution analysis via claims and system analysis in support of the Benefits Configuration and Provider Data departments. The analyst collaborates closely with peers and management to ensure that data sets are analyzed and the research is reported to all affected areas for fast resolution and claims reprocessing.
* Identify and communicate data quality issues through extensive research by comparing system information to applicable claims based on benefit structure, contract details, and pricing methodologies. * Takes initiative in leading projects and collaborating with others. * Analyze benefit coverage and provider data loaded in the claims payment system to determine the root cause of data quality issues directly affecting claims payment and/or denials. * Initiate claims payment analysis based on internal requests from the Health Plan by partnering with the BI department for applicable reports to determine underpayments and overpayments to providers. * Catalog internal defect results and recommendations then communicating all findings to affected areas and appropriate leadership. * Collaborate and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow to facilitate completion of tasks/goals. * Assist with developing and maintaining departmental goals and objectives as well as personal goal maintenance on a quarterly basis. * Assist in the development of action plans to address system deficiencies to ensure claims correctly adjudicate. * Monitor and track best practices while also reviewing compliance changes/impacts for continuous improvement opportunities. * Identify prevalent trends through data reporting and claims analysis. * Assists in circulating information to staff as needed. * Perform other related duties and special projects as requested. * Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI) * Bachelor's degree or equivalent experience in Healthcare claims adjudication, system configuration, and claims auditing * Knowledge of Medicaid, Medicare Advantage, Tricare and Health Care Exchange programs preferred * Knowledge of CPT/HCPCS, ICD-9, ICD-10 coding, and medical terminology * Ability to organize and prioritize work to meet deadlines * Strong computer application skills including Microsoft Word, Excel, Visio, SQL * Excellent written and verbal communication skills required * Good judgment, initiative, and problem-solving abilities * Ability to handle and resolve complex issues independently * Ability to learn new policies and processes based on written material and observation * Ability to establish and maintain professional, positive and effective work relationships * At least 2 years of experience with claims resolution, claims rework, and/or configuration audit * Healthcare experience with Managed Care experience preferred * System configuration experience preferred * Prior experience working with TRICARE, Texas Medicaid, Medicare Advantage and Health Care Exchange programs are highly desirable.
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