The HPSC Configuration Analyst (CA) is responsible for Analysis, Design, Build and Unit Testing of Provider Contracts and Benefits within the KPCC Platform, to ensure accurate and timely claims payment consistent with the Regional and National artifacts (e.g. contractual arrangement(s) made with the Providers, Employer Groups, etc.). The HPSC Configuration Analyst understands the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in KPCC platform applications to support the accurate and timely payment of claims. Uses Configuration Design templates to create and maintain artifacts (e.g. Build Worksheets to be used as documentation/specifications for 'Certification or National Testing Teams'). Consults appropriate internal partners on issues of interpretation/clarity. Performs other duties as assigned by Management.
Essential Responsibilities:Includes all responsibilities of the Configuration Analyst I andConfigures either Professional & Institutional Providers or Complex Benefits.
Leads business requirements development and solution design process including creation of requirements and design documentation and facilitating sessions with business owners and other team members).
Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment.
Coordinates, researches and resolves debarred and sanctioned provider data and ensures communication of required system updates to Provider Contracting and Claims Operations.
Conducts preliminary evaluation of contractual agreement prior to execution to determine system configurability.
Conducts systems requirement assessment in support of regulatory changes (e.g. ICD-10, ASC, DRG etc).
Analyzes business requirements to determine the best approach for configuration design, testing and implementation.
Analyzes benefit evidence of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums and state/regulatory benefits coverage.
Develops, documents and executes test plans for configuration testing and validates accuracy of data loaded.
Acts as the liaison between business configuration and business owners to ensure that all application and technical-oriented issues relating to the configuration requests/projects are appropriately addressed.
Writes/generates ad-hoc claims impact reports and compiles reconciliation statements.
Tests new version releases relative to system configuration and documents results.
Analyzes and make recommendations to management regarding system enhancements and communicates system problems and impact on operations.
Acts as the subject matter expert regarding Configuration Activities for cross-regional/national initiatives. Assists in establishing, and documenting policies and procedures in support of standardized and accurate configuration.
Validates design, testing and implementation of Configuration.
Provides coaching and mentoring to team members, workload distribution, tracking and workflow management.
Travels for team meetings up 25% of the time.
Contributes to SBAR (Situation, Background, Alternative, Recommendation) process.
ExperienceMinimum three (3) years of experience as configuration analyst / business analyst OR in health insurance or managed care environment or in claims adjudication with knowledge of at least one of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules.
EducationBachelor's degree in business, health care or other applicable field OR four (4) years of experience in a directly related field.High School Diploma or General Education Development (GED) required.
License, Certification, RegistrationN/A
Additional Requirements:Proficiency in Tapestry Modules as determined by management OR Benefits Modules within 6 months of hire into the job. Additional time to acquire certification may be permitted at management's discretion.Proficiency requires a minimum of 75% exam score with a 100% score on the associated projects.Both, Certification and Proficiency levels must be achieved within three times of completing Epic testing. If certification/KP proficiency is a requirement of the position, the individual must pass the application test by the third try. If not, consequences include termination or transition to a different role.Training and testing maybe delivered at Epic or KP Facility.Proficiency in Healthcare and Health Plan terminology, medical coding (e.g. CPT4, ICD9, and HCPCS), provider contract concepts and common claims adjudication practices and General Health plan functions.Intermediate knowledge MS Office Suite of products.Demonstrated ability to research, analyze, design, plan, organize, coordinate, implement, and perform necessary follow-up and closure procedures for system related deliverables.Understand relational databases.Strong experience in documentation, research and reporting.Strong analytical and problem solving skills.Excellent interpersonal, communication, & listening skillsProficiency in healthcare benefits, benefit administration and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycle, along with health insurance industry practices and standards.
Preferred Qualifications:Knowledgeable of state and federal regulations.Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, etc.).Knowledge of Kaiser Permanente Internal processes.Knowledge of Epic Tapestry Modules.Prefer certification in Tapestry Modules (Certification requires a minimum of 80% exam score with a 100% score on the associated projects).