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Contract Configuration Analyst

Company: Fallon Health
Location: Leominster
Posted on: November 20, 2022

Job Description:

Overview:About Fallon Health: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 delivers equitable, high-quality coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. 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 impacts the end result of Fallon's health plans as well as the quality of claims operations, customer care operations, and cost containment & recovery operations. With a strong dedication to excellent work quality, 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 Contract configuration team is responsible to ensure that claims are paid correctly based upon the contract configuration, medical policies, reimbursement policies, claims editing policies, EOHHS and CMS requirements.Responsibilities:Job Responsibilities:Performs configuration based upon varying reimbursement methodologies such as APR-DRG, MS-DRG, OPPS, APC Grouper, RBRVS and PharmacyMaintains detailed knowledge of hospital, ancillary and professional billing include CPT, HCPS, DRG and Ambulatory Surgery CodingResearches and stays current with change in CMS Medicare and Medicaid reimbursement modelsAdvances best practices in documentation, data quality and data managementAdheres to contract quality metricsParticipates in any audits (CMS, Internal, etc.) and provides remediation responses in short order when necessaryExecutes accurate fee for service and value-based contracting configurationSupports the development and execution of ad-hoc data requests needed to support various business needsEnsures SOC and Model Audit Controls (MAR) are designed and functioning appropriatelyDevelops and keeps current existing Policies and ProceduresCompletes all edits and call tracking cases are completed within applicable SLAAnalyzes code publications in addition to new or updated policies to assess and respond to impact on configuration and related processesExplores process improvement opportunities as well as mentors new and current team membersExpedites implementation delays and escalates issues to management as appropriateServes as the subject matter expert as it relates to configuration tasks and manages issues to a positive outcomeActively participates, and facilitates as needed, in meetings related to contract configurationDevelops and executes test plans as is relates to core system upgrades such as QNXT or SymplirMaintains current knowledge of pricing applications and code editing softwareExecutes upon all business goals with quality and effectivenessMaintains thorough and concise documentation for trackingAssists with the development of configuration standards and best practicesHandles fluctuating volumes of work and prioritizes work to meet deadline and business needs independentlyEscalates identified issues, makes recommendations, and implements configuration changes to improve the accuracy and efficiency of processesWorks independently with the Network Development team to understand and implement contract requirementsMaintains current knowledge of industry standard code sets, government regulations as mandated by the regulatory agencies such as NCQA, CMS, NPI, etc.Other duties as assignedQualifications:Education:Bachelor's degree in business or equivalent business experienceLicense/Certifications:N/AExperience:Minimum 4-7 years working in the Healthcare industry with detailed provider contract configuration knowledge on Regulatory products such as Medicaid, Medicare, Duals, PACE, etc.Systems thinking - must understand systems/people and the impact of business changes particularly as they affect internal and external business partnersStrong communication skills (formal and informal, written and verbal)Ability to handle multiple demands must be able to balance multiple priorities (i.E., contract configuration, working edits, etc.)Quick learner who can act as an advocateProficient in Microsoft product suite (i.E., Word, Excel, Power Point, etc.)Highly organized problem solver with understanding of system capabilities and business need; deep knowledge of systems at hand3-7 years' experience with QNXT or similar database is required in Healthcare AdministrationPrior experience working with and responding to customer service cases, claims administration, enrollment or appeals and grievances related to inaccurate configuration informationFallon Health Vaccination Requirements:To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as "Remote" require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.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.

Keywords: Fallon Health, Leominster , Contract Configuration Analyst, Professions , Leominster, Massachusetts

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