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23 Feb 2018
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Responsible for the codification and mapping of benefit product building, including the development and maintenance of the benefit configuration document and attaching appropriate service rules required for each benefit category. Serve as a subject matter expert in all areas of the medical plan configuration, medical utilization edits, service payment limits and service rules. Develop workflows and business processes to ensure timely and accurate system build. Act as a facilitator to accurately translate product benefit and all aspects of the service rules into a configurable document. Ability to executive configuration in multiple administrative platforms (i.e., Facets, Health Rules, expertise preferred in Pega PCS). The coder will provide business requirements to core configuration for purposes of translating benefit, clinical coding and payment concepts into system configuration requirements.

The coder will provide guidance to fellow team members regarding documentation concerns as they relate to coding and billing.

Validates the ICD-9-CM / ICD-10-CM code groupings billed on the medical claim and DRG assignments appropriateness to ensure consistency and efficiency in professional and inpatient claims processing, benefit accumulation, data collection, claim payments and quality reporting. Analyze data, report results, findings and recommendations to the product owners, business architects and customers and assist with the development of process improvements to maintain data structures and quality.

  • 10+ years of healthcare insurance payer systems experience (Pegasystems, Visiant (ikaSystems), Facets, QNXT, Xcelys, Amisys etc).
  • Lead configuration effort including other Business Analysts, meeting including the customer and other project team members
  • Coordinate the benefit design, configuration and implementation effort
  • Experience with configuration design and execution of benefits
  • Experience with setting up/developing a standard for benefit administration
  • Experience with data workflows
  • Creation of business process workflows
  • Experience in life cycle management.