Configuration Analyst

Health Plans Configuration Analyst

The Health Plans Configuration Analyst is responsible for the accurate setup, maintenance, and testing of health plan benefit configurations within the organization's core claims and benefits administration systems. This role ensures that plan designs, fee schedules, benefit rules, and adjudication logic are correctly implemented and functioning in alignment with contract requirements, regulatory mandates, and operational specifications.

The Configuration Analyst serves as a critical link between health plan product design, operations, IT, and claims teams — translating complex benefit plan requirements into precise system configurations that drive accurate claims payment and member benefit delivery.

Key Responsibilities

Plan Configuration & Build

• Configure and maintain health plan benefit structures in core administration systems (e.g., QNXT, FACETS, TriZetto, Macess, or equivalent platforms).
• Set up and update plan benefit packages including copays, coinsurance, deductibles, out-of-pocket maximums, and coverage limits across lines of business (Commercial, Medicare, Medicaid, Exchange).
• Build and maintain fee schedules, provider contract rates, reimbursement methodologies, and payment rules.
• Implement benefit exceptions, riders, and custom plan designs per client or regulatory requirements.
• Configure claim editing rules, adjudication logic, and auto-adjudication pathways to ensure accurate and efficient claims processing.

Testing & Validation

• Develop and execute test scenarios to validate configuration accuracy prior to production implementation.
• Perform end-to-end claims testing to confirm that benefit rules, payment logic, and adjudication outcomes align with plan design specifications.
• Identify, document, and resolve configuration defects and discrepancies in a timely manner.
• Collaborate with quality assurance and claims teams to conduct post-implementation audits and retroactive reviews.

Cross-Functional Collaboration

• Partner with product, sales, and account management teams to interpret new plan design requirements and translate them into accurate system configurations.
• Work closely with claims operations to investigate and resolve payment discrepancies, incorrect adjudications, and configuration-related claim errors.
• Coordinate with IT and system teams on system upgrades, platform migrations, and configuration-related enhancements.
• Support provider contracting and network teams with fee schedule builds and contract rate implementation.
• Participate in open enrollment, plan year renewals, and regulatory change implementations, ensuring all configuration updates are completed accurately and on schedule.

Documentation & Compliance

• Maintain comprehensive documentation of all configuration builds, changes, and approvals in accordance with change control policies.
• Ensure configurations comply with CMS, state Medicaid agency, ACA, and other applicable regulatory requirements.
• Support internal and external audits by providing configuration documentation, test results, and change logs.
• Monitor regulatory updates and plan year changes that impact system configuration and proactively flag required updates.

Requirements

• Associate's or Bachelor's degree in Healthcare Administration, Information Systems, Business, or a related field; equivalent work experience considered.
• 2–5 years of experience in health plan configuration, benefits administration, or claims operations within a managed care or payer environment.
• Hands-on experience with one or more claims/benefits administration platforms (e.g., QNXT, FACETS, TriZetto, Macess, Facets, or similar).
• Strong understanding of health plan benefit structures across one or more lines of business: Commercial, Medicare Advantage, Medicaid, or Exchange/ACA.
• Knowledge of claims adjudication principles, reimbursement methodologies (DRG, APC, RBRVS, fee-for-service), and COB rules.
• Familiarity with ICD-10, CPT, HCPCS, and revenue code sets as they relate to benefit configuration and claims processing.
• Strong analytical and problem-solving skills with high attention to detail.
• Proficiency in Microsoft Excel (including data analysis and validation); experience with SQL a plus.
• Ability to manage multiple priorities, meet deadlines, and work effectively in a fast-paced, detail-oriented environment.

Preferred Qualifications

• Experience with Medicare Advantage or Medicaid managed care plan configuration.
• Familiarity with CMS Star Ratings, HEDIS measures, or value-based care contracting as they relate to configuration.
• Experience supporting open enrollment, plan year renewals, or regulatory change cycles.
• Knowledge of HIPAA transaction standards (837, 835, 270/271) and their relationship to benefit configuration.
• Experience with change control processes, UAT documentation, and configuration governance frameworks.
• Prior exposure to provider network configuration, credentialing systems, or fee schedule management.
• Relevant certifications such as CPHQ, CPMA, or health plan administration coursework.