Claims Configuration/Quality Assurance Analyst

Description

Central Coast Salary Range: $76,466- $110,875

Job Summary

This position is responsible for serving as the internal expert on Medi-Cal fee-for-service policies and procedures related to claims and benefits; interpreting State Medi-Cal policy Updates for CenCal Health staff; automation of pricing for claims based on CenCal provider contracts; creating, executing and evaluating end-to-end test plans in conjunction with IT personnel, managing the activities within the plan to ensure that all objectives are met and the solution works as expected. The CCQAA will also be responsible for documenting the test results and leading the acceptance testing for claims configuration projects and will assist with development and on-going support of system editing activities related to claims.

Duties and Responsibilities

• Proactively create and execute test plans to validate new and existing claim configurations; to isolate and report any defects, and validate that such issues are resolved

• Analyze, and recommend provider reimbursement policies to support the Medi-Cal plan and other CenCal Health products

• Analyze and detect incorrect system configuration within CenCal Health’s HIS system

• Participate in the creation, maintenance and testing of the internal reference files within the computer system including, updating the procedure, contract rates, modifier and diagnosis sets for all CenCal Health programs, whether associated with Medi-Cal Updates/APL’s or decisions approved by claims management, or CenCal Health’s governance Committees

• Work in conjunction with IT and Claims staff to improve existing configurations; to configure new policy/requirements systematically

• Work, create and execute test plans based on technical specification for the claims configuration updates and/or system enhancements

• Ensure that deliverables meet the functional and technical specifications and requirements needed by IT for implementation

• Document test outcomes; Hold and facilitate test plan reviews with team members, including IT personnel

• Participate in post-production review sessions to define improvement opportunities

• Assist with the development of Claims Department Desk Reviews and SCF’s for improvements of claims workflows and processes

• Create reports needed in order to review and analyze claims, identify claims requiring retro adjustments, and determine the financial impact of system changes

• Identify and report all possible problems to the appropriate staff so the necessary corrections/improvements can be made, including Provider Services Department staff and providers as necessary

• Coordinate improvement projects and problem resolution with Claims Customer Services;

• Other duties as assigned

Qualifications

Knowledge/Skills/Abilities

• Knowledge of the Medi-Cal program

• Knowledge of CenCal Health’s HIS system

• Knowledge of the Medicare Rate fee schedule

• A good understanding of healthcare business processes and data

• Excellent oral and written communication skills

• Ability to create and maintain logs and various types of spreadsheets

• Attention to detail and strong organizational skills

• Ability to analyze processes and initiate improvements

• Creative problem-solving abilities of data issues

• Ability to understand and create test plans and cases based on written and verbal technical specifications

• Ability to focus on deadlines and deliverables – ability to identify defects quickly

• Ability to think abstractly – ability to identify the defects based on non-conformity

• Ability to think critically and identify areas of improvement.

• Ability to work independently and be self-motivated

• Ability to attend meetings and participate in small teams effectively

• Familiarity with medical terminology

Education and Experience

• Experience supporting the implementation and testing of healthcare systems

• Experience in analysis and troubleshooting of health plan-related claims and provider data issues

• Experienced in the creation and documentation of test cases and test plans 

• Must be proficient in the MS Suite of software and have advanced skills in Excel

• Familiarity with programming processes

• Three – five (3-5) years of experience in a healthcare setting (health plan, clinic, medical group or facility)

• Prior experience in claims system configuration and process improvement

Salary : $76,466 - $110,875