Benefit Configuration Analyst
Posted on Jun 14, 2019 by Wellcare
Reports to: Senior Manager of Configuration
Department: OPS Configuration
Job Type: Non-Exempt
Collects and analyzes data to evaluate operational obstacles which include revenue and compliance issues, and makes recommendations to resolve issues in a timely matter. Uses the medical classification system to design the benefit packages with proper ICD-9, CPT-4, HCPCS for configuration into the Peradigm System. Disseminates benefit determinations to key stakeholders administering benefits (health services, configurations, etc.) throughout the organization. Serves as an integral role in the testing, analysis and benefit configuration of new and existing plans.
- Reviews, analyzes and translates diagnostic procedural phrases into coded form.
- Updates and maintains adjudication system with defined code sets in logical order.
- Coordinates with internal operations departments to ensure data accuracy.
- Produces reports from the Peradigm System to analyze necessary modifications to codes sets, BRULES and MEDEFs.
- Creates testing scripts for new and existing plans.
- Assists in the on-going evaluation of the benefit configurations within the Peradigm System for new and existing benefit plans.
- Documents the configuration of new plans as well as changes in existing plans.
- Provides feedback to stakeholders regarding feasibility and requirements for enhancements to benefit configuration.
- Provides research assistance for the resolutions of benefit issues.
- Serves as a liaison of benefit configuration to external departments.
- Collects and analyzes data to evaluate operational difficulties and makes recommendations to solve problems.
- Performs special projects as needed.
- Required An Associate's Degree in CIS, BIS, or coding
- Required or equivalent work experience
- Required 2 years of experience in medical coding and configuration
- Intermediate Other Applies coding knowledge to ascertain codes sets for each service
- Intermediate Other Ability to break procedures down at a granular level and organize data in a logical manner
- Intermediate Other Ability to conduct Internet research to update code sets
- Preferred RMC certification
- Required Intermediate Peradigm (Diamond)
- Preferred Intermediate Microsoft Access
- Preferred Intermediate SQL Server System
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Preferred Intermediate Other Knowledge of organization of data within medical adjudication systems
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at . EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.