MSO System Configuration Analyst I

The MSO System Configuration Analyst is responsible for the major managed care systems configurations, including EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, health plan implementations and conversions within the System Configuration team.

The primary responsibilities include the accurate interpretation of specific state and/or federal guidelines that impact Medicare and/or Medi-Cal benefits, NEMS risk contracts, codification, and business requirements and converting them into configuration parameters within the core systems. Identify regular fee schedule updates as published by CMS and DHCS and transform into system configuration scheme. Monitor monthly encounter data and report submissions to contracted Plans, DHCS, and CMS; review correspondence and take appropriate follow up actions to accomplish data accuracy and completeness requirements for all managed care programs including PACE, Medicare Advantage and Medi-Cal. Develop reports to monitor system performance and promote integration and automation of systems workflows. Other responsibilities include maintenance of benefit modules, provider profiles set-up (demographic and contracts affiliations), fee schedules, regular coding updates and various system tables through the user interfaces.

The position is also required to produce data reports as demanded by contracted health plans, DHCS, and CMS; reconcile eligibility and capitation data discrepancies between plans and NEMS data; prepare statistic reports to support decision making in managed care business developments. This position will assist in the regular internal review, analysis and audit to all PACE related data issues; identify errors and propose resolutions; collaborate internally with PACE team and communicate externally with entities including DHCS, CMS, PDAC, PharmaStar, etc. to resolve discrepancies and dissimilarities. This position requires significant level of critical thinking skills, current technical knowledge of MSO operations, processes, workflows, and understanding to the managed care operational structure, coding, benefits, and relevant degree of creativity and latitude.

ESSENTIAL JOB FUNCTIONS

• Interprets state and federal guidelines that impact managed care system configuration and convert configuration parameters within the MSO core systems, including updates and changes in benefit coverages, fee schedule rates, provider geographic rate adjustments, EDI transmission and date specifications, report submissions and timelines, etc.
• Develops, loads, edits, and maintains EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, and any additional system configuration items; automate system workflows to promote operational efficiency.
• Performs analytical reviews and technical supports for defining, tracking, and resolving issues in the managed care core systems.
• Monitor monthly encounter data and other report submissions to contracted Health Plans, DHCS, and CMS; review correspondence reports and take appropriate follow up actions to accomplish data accuracy and completeness requirements, for all managed care programs including PACE, Medicare Advantage and Medi-Cal.
• Responsible to independently perform regular internal review, analysis and audit to all PACE related data issues; identify errors and propose resolutions; communicate and collaborate internally with PACE team and externally with entities including DHCS, CMS, PDAC, PharmaStar, etc. to resolve discrepancies and dissimilarities.
• Assist in conducting system testing, validation and analyze outputs and results to allow for continuous improvement of the overall QA process for the MSO EZ-Suite system accuracy, integrity, and performance.
• Communicates with other MSO operational teams to understand workflow needs; design, develop and refine Work Queue processes in core managed care systems to strengthen system enhancement activities including data mapping, system integration and workflow automation to meet and improve operation needs.
• Creates and analyzes statistics reports for other operational teams in assist of evaluating business performance links to MSO medical management services.
• Designs training courses and creates training materials to support EZ-Suite users; initiate training and retraining sessions to support department operations and ensuring users are properly updated to maximize system performance.
• Responds to system configuration flaws/errors and unresolved issues, report and propose to MSO Director and EZCAP Product Development team for resolutions.
• Creates data reports per health plans’ delegation agreement; reconciles eligibility and capitation data discrepancies between contracted Health Plans, DHCS, CMS and NEMS data.
• Supports MSO audit activities performed by various entities, including contracted Health Plans, DHCS, and CMS.
• Prepares other additional statistical reports to support decision making in managed care business development and to support operational initiatives and activities.
• Performs other job duties as required by manager/supervisor.

QUALIFICATIONS

• Completion of a 4-years degree from an accredited University in System Analysis, Computer Programming or other relevant area of study.
• Three (3) years technology and business analysis experience in Managed Health Care industry with working knowledge of how Benefits, Rates, Fee Schedules, and Provider Contracts impact the payment and processing of claims;

• Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, HL7, X12, and ICE standards), particularly DHCS/Medi-Cal guidelines;
• Working knowledge of healthcare standard code sets, benefits, DOFR, RBRVS, and fee schedules;
• Must have strong analytical and problem-solving skills across a wide variety of configuration and technical issues.
• Demonstrated ability to use Microsoft Access, Excel, Crystal Reports, Report Builder and SQL Server Reporting Services.
• Ability to self-manage in a detail-oriented environment.
• Good organization and prioritization skills, outstanding in time management.
• Ability to reliably and consistently deliver quality work product on target dates.
• Strong written and verbal communication skills to allow for effective communication at any level.

LANGUAGE

• Must be able to fluently speak, read and write English.
• Fluent in other languages are an asset.

STATUS

This is an FLSA NON-exempt position.
This is not an OSHA high-risk position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS

Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).