Configuration Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Configure and oversee health plan benefit structures within core administration systems like QNXT, FACETS, TriZetto, Macess, or similar platforms.

• Establish and modify plan benefit packages, including copays, coinsurance, deductibles, out-of-pocket maximums, and coverage limits across various lines of business such as Commercial, Medicare, Medicaid, and Exchange.

• Create and manage fee schedules, provider contract rates, reimbursement methodologies, and payment rules.

• Implement benefit exceptions, riders, and custom plan designs based on client or regulatory requirements.

• Set up claim editing rules, adjudication logic, and auto-adjudication pathways.

• Develop and execute testing scenarios to ensure configuration accuracy prior to production rollout.

• Conduct comprehensive claims testing to validate benefit rules, payment logic, and adjudication results.

• Identify, document, and rectify configuration defects and discrepancies.

• Collaborate with quality assurance and claims teams on audits post-implementation and retroactive reviews.

• Work closely with product, sales, and account management teams to interpret plan design requirements and translate them into system configurations.

• Engage with claims operations to investigate and resolve payment discrepancies, incorrect adjudications, and configuration-related claim issues.

• Coordinate with IT and system teams regarding upgrades, platform migrations, and configuration enhancements.

• Assist provider contracting and network teams with the development of fee schedules and the implementation of contract rates.

• Participate in open enrollment, plan year renewals, and the implementation of regulatory changes.

• Maintain documentation of configuration builds, changes, and approvals according to change control policies.

• Ensure all configurations comply with CMS, state Medicaid agency, ACA, and other relevant regulatory requirements.

• Provide support for internal and external audits with necessary configuration documentation, test outcomes, and change logs.

• Monitor regulatory updates and plan year modifications, flagging necessary configuration adjustments.

⛳️ Requirements

• Associate's or Bachelor's degree in Healthcare Administration, Information Systems, Business, or a related discipline; equivalent work experience will also be considered.

• 2–5 years of experience in health plan configuration, benefits administration, or claims operations within a managed care or payer setting.

• Practical experience with one or more claims/benefits administration platforms (e.g., QNXT, FACETS, TriZetto, Macess, or similar).

• Strong understanding of health plan benefit structures across various lines of business: Commercial, Medicare Advantage, Medicaid, or Exchange/ACA.

• Knowledge of claims adjudication principles, reimbursement methodologies (including DRG, APC, RBRVS, fee-for-service), and COB regulations.

• Familiarity with ICD-10, CPT, HCPCS, and revenue code sets in relation to benefit configuration and claims processing.

• Strong analytical and problem-solving capabilities with a keen attention to detail.

• Proficiency in Microsoft Excel (including data analysis and validation); experience with SQL is advantageous.

• Ability to manage multiple priorities, meet deadlines, and perform effectively in a dynamic, detail-oriented environment.

• Preferred: Experience with Medicare Advantage or Medicaid managed care plan configuration.

• Preferred: Knowledge of CMS Star Ratings, HEDIS measures, or value-based care contracting as they pertain to configuration.

• Preferred: Experience in supporting open enrollment, plan year renewals, or regulatory change cycles.

• Preferred: Understanding of HIPAA transaction standards (837, 835, 270/271) and their connections to benefit configuration.

• Preferred: Experience with change control processes, UAT documentation, and configuration governance frameworks.

• Preferred: Prior exposure to provider network configuration, credentialing systems, or fee schedule management.

• Preferred: Relevant certifications such as CPHQ, CPMA, or coursework in health plan administration.

🏝️ Benefits

• Comprehensive health coverage, including medical, dental, and vision.

• Retirement savings plan with company matching contributions.

• Generous paid time off and holiday schedule.

• Opportunities for professional development and career advancement.

• Flexible work environment and remote work options.