Healthcare Configuration and Data Integrity Manager

Overview The Configuration and Data Integrity Manager is responsible for implementing and interpreting the organization's overall claims, provider configuration, eligibility and provider database management, security, and operations. The Configuration Manager will work with internal departments and external organizations to assure secure data exchanges, integrity, reliability, and availability; plans, organizes and coordinates activities related to the analysis and implementation of network database systems; provides technical guidance and database compliance audits; and consults with business users regarding the use and management of data. Responsibilities Responsible for benefit configuration of covered services, copay, deductibles, coinsurance and max out of pocket in TPA system. Ensure mapping and testing behind the scenes and maintain Matrix of Benefit Packages. Responsible for provider records configuration and contract rate load; create vendors, practice locations, medical group, networks, and reimbursement rate. Collaborate with Provider Relations Department and Credentialing to ensure work distribution and resource management of configuration specialists and data integrity specialists. Provide configuration support to provider contracts; determine if specific agreement received can be entered as noted. Conduct unit testing to ensure design meets specifications as it relates to product upgrades or new releases. Interpret specific contracts and additional business requirements and convert these terms to configuration parameters. Quality control of all information uploaded in the TPA system (e.g., provider data, fee schedules, network assignment, team member responsibilities). Collaborate with provider call center, clinical and claims departments when asked to verify specific provider or benefit configuration information. Provide system configuration support to the organization based on changing business needs. Review and recommend changes to existing configuration processes. Analyze and resolve Claims Workflow regarding Benefit and Contract configuration issues within 3 business days. Provide technical guidance to Data Integrity Specialists in their assigned duties. Oversee configuration of Medicare/Medicaid/Commercial interest rates in the TPA system. Resolve Eligibility Issues with Health Plans. Validate reports run by Data Integrity Specialists on a weekly, monthly, and quarterly basis. Load and maintain fee schedules in the TPA system. Act as liaison between Corporate and the health plan regarding programming development needs related to reporting. Qualifications 3-5 years of Claims Processing experience required. 1-2 years’ experience in healthcare data management. Broad knowledge of medical terminology, customer service, claims processing and/or customary and reasonable cost containment, and coordination of benefits and diagnosis coding. Skills Advanced knowledge ofMicrosoft applications: Outlook, Access database, Excel, Word and basic computer navigation. #J-18808-Ljbffr Provider Network Solutions, LLC