What are the responsibilities and job description for the Health Insurance Configuration Analyst II position at C3?
Title: Health Insurance Configuration Analyst II
Reports to: VP, Payer Solutions
Classification: Individual Contributor
Location: Boston (Hybrid)
Job description revision number and date: V 4.0; 11/25/2024
Organization Summary:
Community Care Cooperative (C3) is a 501(c)(3) non-profit multi-service organization governed by Federally Quality Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We fulfill two primary business functions for the FQHCs we work with. First, we are an FQHC-led accountable care organization (ACO); second, we are a Management Services Organization (MSO) for FQHCs.
We are a fast-growing, dynamic organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.
We have won “Best Places to Work” recognition from the Boston Globe for the last three consecutive years.
SCO and One Care Summary:
The Senior Care Options (SCO) and One Care programs are health plan programs for dually eligible (Medicare and Medicaid) individuals (“duals”) in Massachusetts. SCO serves eligible beneficiaries aged 65 , while One Care serves duals between ages 21-64. These programs are fully integrated dual-eligible special needs plans (FIDE-SNP) that integrate Medicare and Medicaid benefits, along with additional support for enrollees such as integrated care teams, care managers, social supports, etc.
Massachusetts’ Medicaid agency recently conducted a procurement for health plans to offer products in these two programs, for a five-year term starting January 1, 2026. C3 submitted a bid and was selected in September 2024.
Job Summary:
C3 is looking for a Health Insurance Configuration Analyst II to join the Claims team. The ideal candidate should have a strong understanding of data and systems that a typical health insurance plan operates. The candidate will be responsible for translating complex health insurance benefit designs into accurate system configurations within a dedicated software platform, ensuring that claims are processed correctly by analyzing provider contracts, member eligibility, fee schedules and benefit rules.
Responsibilities:
- Benefit Plan Configuration: Accurately configure benefit plans within the claims processing system, including deductibles, copays, MOOP, limits, and network restrictions
- Provider Contract Analysis: Interpret provider contracts to correctly set up provider rates, fee schedules, and network participation within the core system
- Data Mapping: Map data between various sources including the core system, EHR, 837, encounter files, data warehouse, and analytics databases
- System Testing, Quality Assurance, Data Validation
- Ensure compliance with healthcare regulations and guidelines as well as make certain that the system configurations adhere to compliance standards
- Collaborate with other C3 departments: Project Management, IT, Clinical, Customer Service
- Maintain detailed documentation of system configuration, benefit plan details, and process workflows for reference and training purposes
- Participate in continuous improvement initiatives
Required Skills:
- Minimum 2 years of experience in health insurance operations, preferably in benefit plan configuration
- Hands-on experience working with claims adjudication system at a health plan
- Proficiency with data analysis tools, understanding of data structures and experience manipulating large data sets
- Strong analytical and problem-solving ability to identify issues, to investigate causes, and to resolve configuration errors and other system challenges
- Attention to detail
- Written and verbal communication skills
- Ability to handle multiple tasks and prioritize effectively
- Adhering to HIPAA regulations
- Working knowledge of all relevant code sets: CPT, HCPCS, Revenue Codes, ICD-10, Loinc, NDC
Desired Other Skills:
- Experience with Medicaid and Medicare
- Experience with EDPS
- Familiarity with the MassHealth ACO program
- Familiarity with Federally Qualified Health Centers
- Experience with anti-racism activities, and/or lived experience with racism is highly preferred
Qualifications:
- Bachelor’s degree in healthcare administration, business, or related field
** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **
