Payment Configuration Analyst

Avera Health Plans

Worker Type:

Regular

Work Shift:

Day Shift (United States of America)

Pay Range:

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$60840.00 - $91520.00

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

The Payment Configuration Analyst is responsible for maintaining and updating diagnosis-related group (DRG) and ambulatory payment classification (APC) logic within the Optum EasyGroup system. This role ensures accurate claims adjudication consistent application of reimbursement methodologies and compliance with CMS and organizational policies. This position will collaborate closely with teams across Claims IT Provider Contracting and Medical Economics to optimize system performance and support operational excellence in payment accuracy.

What you will do

• Configure and maintain DRG and APC grouping logic in Optum EasyGroup software to reflect CMS updates contract-specific modifications and organizational reimbursement policies.
• Perform onsite testing and validation of DRG/APC logic changes to ensure accuracy and minimize claims payment errors.
• Collaborate with internal teams (e.g. Claims Configuration IT) to support system updates tied to new payment methodologies benefit changes and contract implementations.
• Monitor system behavior and conduct audits to identify configuration errors trends in misgrouped claims or payment discrepancies.
• Interpret CMS regulatory updates and fee schedule releases and apply changes within the system.
• Develop strategies to address or resolve error code processing from grouping software in compliance with Avera Health Plans policy procedure and contract objectives.
• Participate in cross-functional meetings involving payment methodology enhancements new service line implementations or provider contract changes impacting payment rules.
• Document configuration rules decisions and maintenance procedures to ensure transparency and knowledge continuity.
• Respond to escalated issues related to grouping discrepancies or system behavior involving DRG/APC calculations.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others hear understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge skills and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions as long as the accommodations do not cause undue hardship to the employer.

Required Education License/Certification or Work Experience:

• 1-3 years Working with DRG/APC reimbursement methodologies in a health plan hospital billing or claims processing environment.
• Solid understanding of CMS inpatient and outpatient payment systems including IPPS OPPS and Medicare severity DRGs (MS-DRGs).
• Strong attention to detail and ability to interpret technical documentation and payment methodologies.
• Excellent analytical troubleshooting and communication skills.

Preferred Education License/Certification or Work Experience:

• Bachelors in Health Information Management Health Informatics Healthcare Administration or a related field.
• Experience with Optum EasyGroup or similar grouping logic engines (e.g. 3M Grouper TruCode or Optums CES).
• Proficiency in Microsoft Excel and familiarity with data analysis tools or SQL.

Expectations and Standards

• Commitment to the daily application of Averas mission vision core values and social principles to serve patients their families and our community.
• Promote Averas values of compassion hospitality and stewardship.
• Uphold Averas standards of Communication Attitude Responsiveness and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles laws regulations and standards associated with but not limited to CMS The Joint Commission DHHS and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.

• Free health insurance options for full-time single coverage on Avera High Deductible Health Plan

• Up to 5% employer matching contribution for retirement

• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability Veteran Status or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application please call 1- or send an email to .