Configuration Specialist

<strong>Working at Advantasure is more than a job &mdash; you&rsquo;re part of a team that is becoming the country&rsquo;s leading healthcare solutions provider.<br /></strong><br /><strong>A career at Advantasure means you&rsquo;ll be part of one of the most dynamic, diversified and innovative healthcare companies in the nation. You&rsquo;ll be helping our clients make their members healthier &mdash; and our communities a better place to call home.</strong>

Lansing, MI


<p class="p1"><strong>At Advantasure, we partner with healthcare clients to simplify their operations and accelerate their business success. Powered by our broad expertise and a comprehensive suite of product and service solutions, we help health plans effectively navigate the complexity of healthcare.</strong></p>

keywords: job description,quality assurance,compliance,other duties,education,experience,knowledge,work environment,skills


Competitive Compensation and Benefits Package

Overview: <p>This position is responsible for the annual and general configuration and maintenance of Advantasure&rsquo;s core claims system. The successful candidate will be responsible for assisting in the ongoing configuration, management, and oversight of client plan benefits and/or provider contracts.</p> <br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards. Travel is required.</p>
Responsibilities: <ul> <li>Benefits/Plan Configuration &ndash; with a focus on adjudication logic, claims/clinical editing, processing annual Plan Benefit Packages (PBPs), updating cost share, deductibles, member out-of-pocket maximums and regulatory benefit coverage.</li> <li>Interpret complex and simple provider contract methodologies and use critical thinking and problem solving to determine system configurability and solution for non-standard configuration.</li> <li>Configure provider contracts including group and institutional provider contracts, interim rate letters, custom fee schedules, delegated provider contract and capitation arrangements.</li> <li>Responsible for running claims through the system(s) in multiple real-life scenarios to ensure consistency in running and reporting claims, and to ensure compliance with both State and Federal CMS and Medicare Advantage regulations.</li> <li>Perform unit and/or regression testing for new configuration, programming enhancements, new benefit designs, and software changes as necessary that affect claims adjudication.</li> <li>Configuration Testing &ndash; with a focus to ensure the claims system is properly configured to process and adjudicate claims.</li> <li>Create claims and tests/audits claims payment accuracy against benefit and contract methodologies in the claims payment system ensuring compliance with both State and Federal CMS and Medicare Advantage regulations and client specifications as specified by client plans.</li> <li>Develops and improves workflows and business processes within area(s) to improve customer service, decrease operational costs, and improve overall quality.</li> <li>Apply previous experience and knowledge to research, analyze and interpret data to determine appropriate configuration changes and resolve claim/encounter issues and pended claims and update system configuration as necessary.</li> <li>Proactively identifies opportunities and recommends system solutions that increase automation, resolve system deficiencies, and enhance claims processing and reporting to meet and exceed business requirements and decrease operational costs.</li> <li>Act as the subject matter expert regarding claims processing issues. Assists in establishing, and documenting policies and procedures, DLPs and workflows in support of standardized and accurate configuration.</li> <li>Act as a liaison with Client Implementation team to define business requirements and processes as well as QA for new client implementations. &nbsp;</li> <li>Assists personnel, both internally and externally, by answering questions, supplying information, and training in system configuration and setup.</li> <li>Develops and maintains an effective working relationship with customers.</li> <li>Interprets and puts into production CMS changes.</li> </ul>
Requirements: <br /> <p><strong>EDUCATION:</strong></p> <ul> <li>Bachelor&rsquo;s degree in Business Administration, Computer Science, Information Technology, Health Care, or a related field.</li> <li>Relevant combination of education and experience may be considered in lieu of degree.&nbsp;</li> <li>Continuous learning, as defined by the Company&rsquo;s learning philosophy, is required.&nbsp;</li> <li>Certification or progress toward certification is highly preferred and encouraged.</li> </ul> <br /> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Five years experience in claims configuration software is required. &nbsp;</li> <li>Supervisory and/or Analyst experience with proven experience in operational analysis, data analysis, and problem resolution type activities is preferred.</li> </ul> <br /> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Ability to plan, organize, direct, and control projects.</li> <li>Excellent written and verbal communication skills.</li> <li>Ability to lead and contribute to process improvement projects.</li> <li>Working knowledge of PC applications and/or mainframe.</li> <li>Excellent analytical, organizational, and problem-solving skills.</li> <li>Knowledge of Project work with the ability to meet deadlines, understand requirements, and support business deliverables.</li> <li>Ability to work successfully as both a team player and an individual contributor with little supervision.</li> <li>Ability to manage multiple priorities.</li> <li>Claims processing knowledge.</li> <li>Significant creativity to utilize system capabilities to meet benefit design.</li> <li>Ability to develop, implement, and monitor policies and procedures.</li> <li>Proficient in current industry standard PC applications and systems (e.g., Access, Excel, and Word).</li> <li>Ability to travel to business locations.</li> <li>Ability to manage vendors.</li> <li>Ability to demonstrate strong analytical skills and display the &ldquo;own it&rdquo; cultural belief on a daily basis.</li> <li>Knowledge of benefit/claims configuration of facets, Advantasure, or equivalent, for claims and enrollment systems.</li> <li>Knowledge of Medicare Advantage and CMS Regulations.</li> <li>BlueCard knowledge.</li> <li>Knowledge of claims in a Medicare Advantage Organization.</li> <li>Knowledge and expertise in Configuration.</li> </ul>