Overall Purpose: 

The main functions of this position are responsible for leading, coaching and guiding staff that implement, support, and maintain the core administrative system configuration including but not limited to: EDI transactions, provider and member data, encounters, CMS/health plan, internal reporting, benefits, and data entry. This role will be responsible for continuing to enhance the vision, value proposition, services for the configuration function and develop and align the staff in place to deliver against these services.

Education:

• High school diploma or GED required 6 years relevant work experience 

• Bachelor’s degree preferred 

Knowledge, Skills and Abilities: 

Required Skills 

• Must have a strong understanding of any local, state and federal rules regarding the adjudication of medical benefits 

• Strong knowledge of CPT, HCPCS, ICD-10, DRG and APC coding and CMS Guidelines. 

• Strong organizational and time management skills with the ability to prioritize individual workloads.

• Proficient in MS Office with strong computer skills (e.g. multiple systems experiences, keyboarding skills, Microsoft word, Power Point) 

• 5 years of system and configuration knowledge 

• Knowledge of CMS reporting: ODAG and Part C

• 5 years encounter submission experience 

• 3 to 5 years management experience. 

• Extensive experience in plan building, provider data maintenance and reimbursement methodologies including fee schedules, contract management and workflow processes. 

• HMO Claims, managed care and Medicare advantage experience required. 

Preferred Qualifications: 

• Experience analyzing and identifying trends

• Ability to interpret electronic data interchange 

• Ability to drive performance management 

Essential Functions: 

• Coordinate and supervise daily/weekly/monthly activities of a team members including setting priorities for the team to ensure task completion and performance goals are met

• Respond configuration escalations 

• Provide coaching, feedback, and annual performance reviews as well as formal corrective action

• Manage inventory and performance to business metrics

• Write and Submit P&P update requests

• Provide expertise or general system configuration support to team in reviewing, researching, investigating, system configuration 

• Support team employee engagement 

• Communicate and collaborate with internal and external business partners

• Document and communicate status of system configuration to stakeholders as needed

• Achieve applicable performance metrics (productivity, quality, TAT, utilization)

• Advanced problem solving, critical thinking, and process analysis skills to lead teams responsible for client configuration

• Understanding of the healthcare industry, including competitors, the regulatory environment, and industry trends

• Ability to provide strategic leadership and demonstrate the ability to develop future-state scenarios, create a vision for the future, defines factors needed to achieve success, and key actions required.

• Demonstrated leadership skills having lead configuration activity or function, knowledgeable about configuration best practices, methodologies and tools

• Other task assigned by manager