Facets NetworX Configuration Analyst I II III

Lets do great things together

Founded in Oregon in 1955 ODS now Modais proud to be a company of real people committed to quality. Today like then were focused on building a better future for healthcare. That starts by offering outstanding coverage to our members compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places together.

Job Summary:
The Medical Reimbursement Configuration Analystsworks with our most complex pricing configuration. Evaluates designs tests and performs configuration needed to meet the business requirements for contracts of the highest complexity with a substantial variety of pricing methodologies including CMS DRG APC Medicaid RBRVS etc. Assures end results achieve the highest levels of accuracy and claims auto adjudication. Thisis a FT WFH role.

Pay Range
$53596.39 $67000.66annually
*Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page linked below to be considered for this position:

Required Skills Experience & Education:

• Bachelors degree in computer science or healthcare related field or equivalent work experience
• Minimum 35 years experience in the health insurance industry with a strong medical claims background preferred
• Minimum 35 years experience in pricing configuration preferably in Facets and NetworX
• Proficient in interpretation and analysis of provider contracts
• Proven ability to translate complex provider contracts into pricing configuration
• Skilled at configuration lifecycle of analysis design configuration testing and implementation
• Proven problem solving and troubleshooting skills employing outside the box thinking
• Expert MS Excel skills are required
• Demonstrated knowledge of pricing methodologies including but not limited to Medicare and Medicaid DRG SNF RBRVS APC etc.
• Ability to clearly document processes
• Ability to teach configuration skill sets to other staff
• Certified Professional Coder designation and experience is a plus
• PC proficiency with Microsoft office applications and Outlook
• Ability to work well under pressure with frequent interruptions and shifting priorities
• Ability to maintain confidentiality and project a positive and professional business image
• Ability to come to work on time daily
• Ability to work independently with minimal supervision

Primary Functions:

• Analyzes provider contracts for institutional and noninstitutional providers developing business requirements.
• Analyzes pricing business requirements develops and evaluates alternatives prepares proposals and design specifications for complex configuration systems or applications to meet the identified needs goals and metrics.
• Configures and tests results assuring that the highest levels of quality and claims auto adjudication are met.
• Consults with Provider Contracting and/or Analytics to determine appropriate interpretation of contract intent.
• Works with varying and complex pricing methodologies including but not limited to Medicare and Medicaid methodologies Medicaid DRG APC Outliers RBRVS Fee Schedules etc.
• Designs and creates qualifiers within the system to assure appropriate services are priced at the correct rates.
• Evaluates provider set up and works with Provider Data Maintenance team to assure that pricing and provider data are in synch.
• Researches and resolves critical issues that are referred from Claims Customer Service Provider Relations Credentialing Analytics and Appeals.
• Represents the unit on corporate and cross functional projects as assigned.
• Documents processes according to Moda and unit standards.
• Provides training to other staff as assigned.
• Mentors other staff as assigned.
• Attends software vendor subcommittee meetings to further knowledge and keep aligned with system changes and solutions.
• Other duties as assigned

Contact with others &Working Conditions

• Works with others at all levels throughout the organization including Provider Contracting Claims Customer Service Benefit Configuration IT Data Analytics and others with frequently confidential information. Works with outside vendors and staff at other health plans as needed to identify and vet ideas.
• Office environment with extensive close PC and keyboard work constant sitting and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week including evenings and occasional weekends to meet business need.

Together we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race religion color age sex sexual orientation national origin marital status disability veteran status or any other status protected by law. This is applicable to all terms and conditions of employment including recruiting hiring placement promotion termination layoff recall transfer leaves of absences compensation and training.

For more information regarding accommodations please direct your questions to Kristy Nehler & Danielle Baker via email.