Plan Building and System Configuration Specialist

Primary Responsibilities:

• Develop, configure, and maintain healthcare plan designs and benefit configurations in various systems.
• Ensure all plan configurations support auto adjudication and meet regulatory and compliance requirements.
• Regularly review and update plan configurations to reflect changes in healthcare policies and regulations.
• Oversee the integration and interoperability of different healthcare systems to streamline auto adjudication processes.
• Facilitate system upgrades, patches, and maintenance to ensure seamless operation and minimal downtime.
• Collaborate with IT and other departments to implement new technologies and enhancements.
• Perform comprehensive testing of plan configurations to ensure accurate and efficient claims adjudication.
• Identify and resolve any discrepancies or issues in the adjudication process.
• Create and document testing protocols and procedures to maintain high standards of quality and accuracy.
• Work closely with internal and external stakeholders to gather requirements and ensure plan configurations meet organizational and client needs.
• Become a subject matter expert on plan building and system configuration, providing guidance and support to other departments.
• Communicate effectively with stakeholders to keep them informed of project status, issues, and resolutions.
• Maintain detailed documentation of all plan configurations, system changes, and testing procedures.
• Use data and analytics to identify trends, opportunities for improvement, and areas needing attention.

Qualifications:

• Associate’s degree in healthcare administration, information systems, or a related field.
• Minimum of 2 years of experience in plan building, system configuration, and claims adjudication in the healthcare industry.
• Strong knowledge of healthcare policies, regulations, and compliance requirements.
• Proficiency in using healthcare management systems and software.
• Excellent problem-solving skills and attention to detail.
• Effective communication and interpersonal skills.
• Ability to work in a fast-paced environment and manage multiple projects simultaneously.
• Experience with auto adjudication systems and technologies preferred.
• Certification in healthcare information systems or related fields preferred.
• Proven track record of successful system integration and optimization projects preferred.