HealthEdge Specialist

Skills

• 4+ years of HealthCare operations or Healthcare claims processing experience. • Proficiency in Healthcare and Health Plan terminology and medical coding (e.g. CPT HCPCS ICD9 & ICD10 CDT Revenue DRG and other relevant medical and industry-standard codes). • Deep understanding of benefit plans benefits association (package coverage component and detail) benefit coding (Benefit keywords and linkage associations) Claims to process and workflows for multiple Lines of Business including FEP and BCBS Association mandates. • Experience in SQL and other relevant tools and technology used for Benefit configuration updates. • Working knowledge of MS Azure DevOps.

Description

About the Project - You will be part of a team dedicated to processing configuration for Claims, Benefits, and Pricing for a non-profit Healthcare Organization in the US.

Responsibilities

• • Create new and modify existing Claims Pricing configurations. Configures and maintains the business rules within the Claims Processing ecosystem.
• • Configures the HealthRules (benefits and Package pricing) software from development into the testing and deploying to the production environment.
• • Recommends and implements benefit and pricing setup based on knowledge of system configuration capabilities and information obtained from business clients.
• • Independently evaluates business procedures and problems.
• • Hands-on working knowledge in resolving production issues related to Benefit configurations.
• • Identifies research and resolves inaccuracies and inconsistencies in the business rules as they impact claims payment and other upstream and downstream transactions.
• • Resolve configuration defects and perform testing to validate the updates are working as expected.
• • Participates in business requirements gathering sessions to identify specifications and solutions.
• • Evaluate and recommend configuration solutions to Business and IT leadership.
• • Identifies and assesses potential problems and performs and implements system enhancements, modifications, and upgrades.
• • Provides application and technical support for the HealthRules software as well as troubleshooting for end users.
• • Works with IT to define business and IT systems requirements.
• • Identifies and assesses potential problems and performs and implements system enhancements, modifications, and upgrades.
• • Mentors and guides business users with the design and impact of configuration changes.
• • Creates test case scenarios for application and configuration testing and ensures appropriate testing has been completed before the changes are deployed into the production environment.
• • Designs, develops, and maintains user system documentation.
• • Evaluates and monitor coded data elements.
• • Assists users in understanding business system functions.