Kaiser Permanente Configuration Analyst IV in Rancho Cucamonga, California
The Configuration Analyst will understand the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in the existing application (the host processing system), and other platform applications to support the accurate and timely payment of claims for the Regions' Claims systems. Tests new releases, makes recommendations on system enhancements, and evaluates contracts for configuration which includes system capabilities. Consults with appropriate internal partners on issues of interpretation. The Configuration Analyst works with the Product Managers and Developers to define, code, configure and maintain detailed provider/benefit services and provider/benefit plans designs for the applications that require benefit information. The Configuration Analyst helps to bring products to market that meet customer (e.g., member, broker, consultant, employer, etc.) needs and expectations and ensures that product and operational goals are achieved. The Configuration Analyst makes sure benefits are well defined and can be configured in all applications that require benefit data / provider contract data. The incumbent provides consultation and support to all other employees responsible for configuring benefits into Kaiser Permanente benefit systems. The incumbent also ensures that the benefit coding definitions are consistent across the organization. The incumbent will provide subject matter expertise throughout the organization for benefit coding, billing and benefit configuration and ensure consistency and compliance of benefit coding definitions across applications. The Configuration Analyst clearly understands the products and healthcare benefit services offered to our customers, including cost share, limits, accumulators, and regulatory rules and guidelines. The Configuration analyst function will leverage applicable components of the Product Development Management Process (PDMP) or similar processes and Comprehensive Delivery Process (CDP) or similar processes to bring KP products to the market.
Essential Responsibilities: - Includes all responsibilities of the Configuration Analyst II and III. - Provides technical coding and design advice for benefit development in support of product initiatives so that applicable PDMP approval gates or similar approval gates are met and the product plan remains on track (green) status. - Provides expert knowledge, impact analysis and recommendations related to configuration design and understanding impacts of benefit data / provider contract data on all systems that require benefit data / provider contract data and frequently act as a liaison, problem solver and facilitator. - Creates and/or socializes coding definitions for all benefit designs. This work includes tools for project governance, tools and templates, protocols, engagement strategy, escalation protocols, decision-making, risk management and contingency planning. - Develops processes to analyze, design, configure, code and QA detailed benefit designs and provides assistance to all departments on benefit coding issues. - Ensures correct interpretation and definition of benefits. - Develops benefit codes and ensures integration with across all product lines. - Creates and/or manages project plans and timelines to ensure that a given product plan will produce desired results for the targeted market segment and regional operation and/or to meet broader product solutions which would be developed for segment specific strategies. - Identifies and seeks approval for key actions necessary to remediate all problems/issues and makes recommendations to management on steps to ensure product is delivered on time within specifications. - Participates in, and may lead, cross-functional teams of personnel on routine and more complicated scope activities that support Product Development agenda, processes, and programs. - Reviews, creates and incorporates policies and procedures to implement coding best practices and makes recommendations to management on Regional or Program needs to achieve strategic objectives. - Develops and present recommendations and findings to departmental management and cross-functional leadership. Will develop documentation for senior executives and other key stakeholders and communicate all coding changes. - Collaborates with Benefit Managers to ensure that a comprehensive Project Plan exists for all key benefit initiatives and will coordinate and facilitate all work teams to develop benefit codes. - Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment. - Conducts research and resolution of debarred and sanctioned providers and communicate 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 provider contracts to determine the best approach for loading data elements into the claim processing system. - 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 validate accuracy of data loaded. - Consults with business analysts and regional contacts to determine appropriate interpretation and configuration of contract terms and/or evidence of coverage. - Writes ad-hoc benefits and provider reports and compile claims payment reconciliation statements. - Tests new version releases relative to benefits administration and/or provider contract and document results. - Analyzes and make recommendations to management regarding system enhancements needed and communicate system problems relative to member benefits and/or provider contracting. - Acts as the subject matter expert regarding benefits administration and/or provider contracts. Assists in establishing, and documenting policies and procedures in support of standardized and accurate configuration. - Uses MACESS workflow to monitor contract updates and contract(S) matrix/grid. - Performs problem resolution of configuration issues.
Qualifications: Basic Qualifications: Experience - Minimum six (6) years of benefit configuration/coding experience. - Minimum five (5) years in healthcare or managed care. - Minimum three (3) years of experience in documentation, research and reporting required. Education
High School Diploma or General Education Development (GED) required. License, Certification, Registration
- Medical and billing coding certification preferred.
- Expert knowledge in Claims and provider contracts in the appropriate Regional Claims system.
- Understanding of relational databases.
- Thorough knowledge of policies, practices and systems.
- Complete understanding and application of principles, concepts, practices, and standards.
- Full knowledge of industry practices.
- Broad application of principles, theories, and concepts in applicable discipline, plus working knowledge of other related fields.
- Thorough knowledge of benefits, benefit administration and health care delivery from either/both a payor or provider perspective, along with insurance industry practices and systems.
Excellent interpersonal, communication, and listening skills are required. Functional Knowledge & Skills:
Demonstrated competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database is required.
- Knowledge of state and federal regulations
- Strong critical thinking and analysis skills; verbal and written communications, and interpersonal interactions (e.g. partnering, conflict management, consulting, etc.).
- Advanced proficiency in Microsoft Excel.
- Must be able to work in a Labor/Management Partnership environment.
- Minimum four (4) years of experience of related Health Plan, Medical Group, hospital or insurance analytical and/or consulting experience preferred.
- Experience with Center for Medicaid and Medicare (CMS) regulatory guidelines preferred.
- EPIC Benefit Engine, Tapestry AP claims or Diamond claims desirable.
- Intermediate proficiency in Microsoft Access and Query Tools preferred.
Basis proficiency in statistical analysis preferred.
Bachelor's degree in information systems, business or health care administration, or other related field, preferred.
- Master's degree preferred.
COMPANY Kaiser PermanenteTITLE Configuration Analyst IVLOCATION Rancho Cucamonga, CAREQNUMBER 624802
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.