Job description

Position Summary/Position

Under the direction of the Claims System Configuration Supervisor, the Quality Assurance Analyst II is responsible for ensuring the integrity of all claims system configuration created and maintained by the Claims System Configuration team. The Quality Assurance, Analyst II, will audit claims system configured by the Application Architects and Analysts to ensure accurate adjudication of claims. Ensure all Business Rules are configured correctly in the claims system. Support testing efforts within an agile team and execute all levels of testing (System, Data validation, Integration and Regression). The Quality Assurance, Analyst II, will utilize quality auditing tools, identify trainings needs, and collaborate on effective and efficient methods for accurate and quality system configuration. Major Functions (Duties and Responsibilities)

1. Analyze and assess data reports and audit Team Member output to confirm claims system configuration is accurate based on contract interpretation.
2. Work with Claims System Configuration Supervisor to monitor quality standards for Application Architects and Analyst that complete claims system configuration.
3. Review and report audit findings with Supervisor to support requirements of accuracy and productivity.
4. Ensure that all identified errors are corrected, and escalated issues are resolved within a timely manner.
5. In conjunction with the Claims System Configuration Supervisor and management, formulate improved processes for data accuracy and integrity and assist with identifying training needs.
6. Generate and audit data management reports to ensure appropriate billing and handling practices.
7. Responsible for reviewing the Claim Check Run Audit and resolving any issues or discrepancies.
8. Conduct in-depth root cause analysis for claims system configuration related issues that arise from claims and integrated system errors. Use clear and concise language. Define quantitative language, such as large, difficult, complex.
9. Review regulatory guidelines to determine if claims system configuration updates are necessary.
10. Assist with the development of configuration standards and best practice guides for maintaining efficiency, accuracy, automation and successful integration with internal and external systems and programs.
11. Analyze and identify system configuration based on claims auto adjudication standard metrics and business operational requirements.
12. Maintain a library of system requirements, specifications, test cases, defect logs, and test results.
13. Responsible for UAT (User Acceptance Testing) test plan preparation and test execution of product delivery initiative(s), crossing multiple applications.
14. Identify and communicate impact of system enhancements or configuration changes on integrated systems and processes.
15. Develop and run automated test scripts and evaluate results.
16. Assist Claims System Configuration team with special projects as needed. Experience Qualifications

Three to five (3-5) years of experience of auditing complex system configuration. Three to five (3-5) years of experience in Managed Care required. Preferred Experience

Experience with claims analysis is preferred. Experience in major managed care system migration/implementation preferred. Education Qualifications

Bachelor’s degree in IT or Business from an accredited institution required.

Significant experience may be considered In lieu of degree: In lieu of a degree, a minimum total of seven (7) years of experience is required: Four (4) years general healthcare experience plus three (3) years of claims analysis experience is required. Knowledge Requirement

Extensive knowledge of CPT, HCPCS, Revenue, ICD-10 Coding rules and guidelines. Knowledge of general managed care operations required; delegated plan model preferred. Knowledge of CMS, DHCS, DMHC, NCQA rules and regulations preferred. Working knowledge of Encounters, EDI submissions, provider web portals, integrated NCCI applications, and overall data mapping. Knowledge and understanding of system and application process integrations and algorithms. Knowledge of Medicare and Medi-Cal benefit structure and regulatory billing guidelines. Knowledge of Medical Claim Processing Guidelines. Proficient knowledge of relational database structure. Skills Requirement

Develop test cases and document results. Skilled in Microsoft Excel and Access applications. Exceptional problem solving and critical thinking skills. Strong presentation and written communication skills. Abilities Requirement

Work independently and solve complex problems with little to no assistance. Effectively manage competing priorities. Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

A reasonable salary expectation is between $79,813.76 and $101,762.54, based upon experience and internal equity.

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

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