Benefit & Provider Configuration Analyst

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

Responsible for translating standard and complex and varied business needs into Fallon Health configuration rules. To be successful, must possess the technical expertise of the required operational phases of the business systems and analysis skills to translate the information accurately. Business acumen is essential to fully understand the implications of the configuration role on other interrelated businesses related to benefits and provider contracts.

The configuration work for which this role is responsible impacts the end result of our health plans as well as the quality of our claims operations, customer care operations, and cost containment & recovery operations. With a strong dedication to excellent quality of work, it ensures that our members and providers have a positive experience as part of the Fallon Health network, and that we pay claims correctly and on time, avoiding fines and extra costs.

The benefit & provider configuration team is responsible for ensuring that claims payment and benefits are correctly configured in context of medical policies, reimbursement policies, clinical editing policies, CMS requirements and contract details. Accurate systems configuration ensures the correct adjudication of claims and processing of provider payments for the providers in the Fallon Health managed care networks.

Primary Job Responsibilities

Benefit configuration and associated testing
• The large segment of the position entails both standard and complex benefits and provider claims payment configuration into Fallon Health's operating system, QNXT. Accuracy must be maintained in conjunction with service level Agreements (SLA) and established quality measures
• Ensures all edits (Benefit and Provider) and Benefit call tracking cases are completed within applicable SLA on a timely basis
• Analyzes code publications in addition to new or updated policies to assess and respond to impact on configuration and related processes
• Explores process improvement opportunities as well as mentors new and current team members
• Expedites implementation delays and escalates issues to upper management as appropriate
• Serves as the subject matter expert as it relates to configuration errors and manages issues to a positive outcome
• Actively participates as a representative in meetings, and facilitates as needed, as it relates to benefit configuration
• Documents results relating to QNXT, runs queries and develops back end file loads when applicable, and any product upgrades
• Fully supports internal audits and responds timely to any resulting action plans
• Responds to RFPs in a timely manner
• Partners with IT on relationship management for Cognizant.
• Leads role in operational projects in collaboration with business operational subject matter experts as they arise
• Analyzes QCS tool with all new upgrades, including testing and implementing changes.
• Fully understands Provider Logic Linking in QNXT for appropriate claims payment.

Bachelor's degree in business or equivalent business experience

License/Certifications:

n/a

Experience:

• 3-7 years' experience with QNXT or similar database is required in Healthcare Administration
• Strong operational knowledge of commercial/regulatory health provider industry
• Prior experience working with and responding to customer service cases, claims administration, enrollment or appeals and grievances related to inaccurate configuration information
• Experience of benefit configuration with the ability to analyze and translate complicated data into useful information
• Understanding of industry standard code sets, government regulations as mandated by the regulatory agencies such as NCQA, CMS, NPI.
• Strong analytical & quantitative skills to identify member or provider impacts downstream as a result of invalid configuration.
• Intermediate Microsoft Office experience with an emphasis on MS Excel and Access skills in order to manipulate and communicate complex data; MS Access or SQL knowledge preferred
• Project management experience preferred
• Highly organized with the ability to effectively manage multiple projects simultaneously
• Ability to work well independently as well as win as a team through mentorship of less experienced analysts.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.