Benefits Configuration Analyst

About NYC Health + HospitalsMetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus'' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. Position OverviewDevelop and manage clinical benefit configuration process to ensure timely and accurate claims payment system configuration and claim processing. Responsible for the codification and mapping of benefit product building, including the development and maintenance of the benefit configuration document and attaching appropriate servicerules required for each benefit category. Serve as 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. Provide business requirements to CORE configuration for purposes of translating clinical concepts into system configuration requirements. Provide guidance to employees and providers regarding documentation concerns as they relate to coding and billing.Job DescriptionDevelop workflows and business processes to ensure timely and accurate clinical claims payment system configuration (benefit configuration)Translate clinical product benefits and all aspects of the service rules for system configurationProvide business requirements to CORE configuration for benefit buildSupport quality review and testing of all benefit setup prior to implementation and go-livePartner with IT Claims and Compliance departments to audit setups and configuration post go-liveResolve escalated and complex processing, change requests, issues, or questionsManage and maintain benefit documentation for internal & external customersAnnual review of new CPT & HCPCS code coverage determinations, considering member benefits, medical necessity and industry standard coverage policiesResponsible for own workflow assignments and must be able to take the initiative to resolve problems and meet deadlinesMinimum Qualifications3-5 years health plan benefit configuration experienceCertification as a professional coder (CPC) - preferred1+ years medical coding experience with demonstrated sustained coding qualityAdvanced knowledge of CPT/HCPCS/Revenue Code, procedure coding, ICD10 coding, principles and practicesIn-depth knowledge of coding/classification systems appropriate for inpatient, outpatient, HCC, CRG and DRGAbility to research authoritative citations related to coding, compliance, and additional reporting needs Demonstrates overall knowledge of claims processing for various insurances both private and governmentExcellent computer skills, able to learn, use and toggle between multiple systemsAnalytical skills and ability to create reports, charts and graphs (e.g. Microsoft Excel)Ability to work independently or in a team setting, while handling multiple projects and adjusting to changes quickly while meeting all deadlinesProfessional CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical skillsWritten/Oral Communication

Created: 2021-11-29