Kaiser Permanente Senior Validation Analyst in Atlanta, Georgia
The HPSC Configuration Analyst (CA) is responsible for Analysis, Design, Build and Unit Testing of Provider Contracts and Benefits within the KPCC Platform, to ensure accurate and timely claims payment consistent with the Regional and National artifacts (e.g. contractual arrangement(s) made with the Providers, Employer Groups, etc.). The HPSC Configuration Analyst understands the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in KPCC platform applications to support the accurate and timely payment of claims. Uses Configuration Design templates to create and maintain artifacts (e.g. Build Worksheets to be used as documentation/specifications for 'Certification or National Testing Teams'). Consults appropriate internal partners on issues of interpretation/clarity. Performs other duties as assigned by Management.
Includes all responsibilities of the Configuration Analyst II and:
Configures either Professional & Institutional Providers or Complex Benefits.
Provides technical coding and design advice for benefit development in support of product initiatives so that applicable PDMP approval gates or similar approval gates are met and the product plan remains on track (green) status.
Provides expert knowledge, impact analysis and recommendations related to configuration design and understanding impacts of benefit data / provider contract data on all systems that require benefit data / provider contract data and frequently act as a liaison, problem solver and facilitator.
Creates and/or socializes coding definitions for all benefit designs. This work includes tools for project governance, tools and templates, protocols, engagement strategy, escalation protocols, decision-making, risk management and contingency planning.
Develops processes to analyze, design, configure, code and QA detailed benefit designs and provides assistance to all departments on benefit coding issues.
Ensures correct interpretation and definition of benefits.
Develops benefit codes and ensures integration with across all product lines.
Creates and/or manages project plans and timelines to ensure that a given product plan will produce desired results for the targeted market segment and regional operation and/or to meet broader product solutions which would be developed for segment specific strategies.
Identifies and seeks approval for key actions necessary to remediate all problems/issues and makes recommendations to management on steps to ensure product is delivered on time within specifications.
Participates in, and may lead, cross-functional teams of personnel on routine and more complicated scope activities that support Product Development agenda, processes, and programs.
Reviews, creates and incorporates policies and procedures to implement coding best practices and makes recommendations to management on Regional or Program needs to achieve strategic objectives.
Develops and presents recommendations and findings to departmental management and cross-functional leadership. Will develop documentation for senior executives and other key stakeholders and communicate all coding changes.
Collaborates with Benefit Managers to ensure that a comprehensive Project Plan exists for all key benefit initiatives and will coordinate and facilitate all work teams to develop benefit codes.
Maintains detailed knowledge and understanding of the host Claims processing system rules relative to claims payment
Conducts research and resolution of debarred and sanctioned providers and communicate required system updates to Provider Contracting and Claims Operations.
Conducts preliminary evaluation of contractual agreement prior to execution to determine system configurability.
Conducts systems requirement assessment in support of regulatory changes (e.g. ICD-10, ASC, DRG etc).
Analyzes provider contracts to determine the best approach for loading data elements into the claim processing system.
Analyzes benefit evidence of coverage to determine best approach for loading benefits plan offered including co-pays, out-of-pocket maximums and state/regulatory benefits coverage.
Develops, documents and executes test plans for configuration testing and validate accuracy of data loaded.
Consults with business analysts and regional contacts to determine appropriate interpretation and configuration of contract terms and/or evidence of coverage.
Writes ad-hoc benefits and provider reports and compile claims payment reconciliation statements.
Tests new version releases relative to benefits administration and/or provider contract and document results.
Analyzes and make recommendations to management regarding system enhancements needed and communicate system problems relative to member benefits and/or provider contracting.
Acts as the subject matter expert regarding benefits administration and/or provider contracts. Assists in establishing, and documenting policies and procedures in support of standardized and accurate configuration.
Uses MACESS workflow to monitor contract updates and contract(S) matrix/grid.
Performs problem resolution of configuration issues.
Travels for team meetings up 50% of the time.
Authors to SBAR (Situation, Background, Alternative, Recommendation) process.
May act as an informal Team Lead.
Provide coaching to team members and workload distribution as directed by manager.
- Minimum five (5) years of experience as a configuration analyst / business analyst or five (5) years in healthcare or managed care (such as claims adjudication) with knowledge of at least one of the following: membership, benefits, provider contracts & pricing, medical reviews, referral authorizations and code review and fee schedules.
Bachelor's degree in Information Systems, Business, Health Care Administration, related field OR four (4) years of equivalent experience in a directly related field.
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
Proficiency in Tapestry modules as determined by management OR Proficiency in Benefits Modules within 6 months of hire into the job. Additional time to acquire certification may be permitted at management's discretion.
Proficiency requires a minimum of 75% exam score with a 100% score on the associated projects.
Both, Certification and Proficiency levels must be achieved within three times of completing Epic testing. If certification/KP proficiency is a requirement of the position, the individual must pass the application test by the third try. If not, consequences include termination or transition to a different role.
Training and testing maybe delivered at Epic or KP Facility.
Demonstrated intermediate competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database is required.
Knowledge of state and federal regulations.
Strong critical thinking and analysis skills; verbal and written communications, and interpersonal interactions (e.g. partnering, conflict management, consulting, etc.).
Advanced proficiency in MS Office Suite of products.
Thorough understanding of relational databases.
Significant experience in documentation, research and reporting.
Excellent interpersonal, communication, and listening skills are required.
Complete understanding and application of principles, concepts, practices, and standards.
Advanced knowledge in healthcare benefits, benefit administration and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycle, along with health insurance industry practices and standards.
Basis proficiency in Statistical analysis.
Knowledge of Certification/Accreditation Standards (NCQA, JCAHO, CMS, etc.).
Knowledge of Kaiser Permanente Internal processes.
Knowledge of Epic Tapestry Modules.
Prefer Certification in other Tapestry modules. Certification requires a minimum of 80% exam score with a 100% score on the associated projects
TITLE: Senior Validation Analyst
LOCATION: Atlanta, Georgia
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.