The MSO System Configuration Analyst is responsible for the major managed care systems configurations, including EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, other wrap-around applications and health plan implementations and conversions within the System Configuration team. Responsible to perform validation testing to production database post system upgrades and installation of new modules, implementation of hotfixes, etc. which requires after-hour/weekend operation independently without onsite supervision.

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. Strengthen system enhancement activities including data mapping, system integration and workflow automation. Other responsibilities include maintenance of benefit modules, provider profiles set-ups and regular audits (demographic and contracts rates/affiliations), fee schedules, regular coding updates and various system tables through the user interfaces.

This position is responsible to independently perform 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.

The position requires the ability to produce data reports as demanded by contracted health plans, DHCS, and CMS; reconcile eligibility, capitation, claims and authorization data discrepancies between plans and NEMS; prepare statistical reports to support decision making in managed care business developments.

This position requires significant level of critical thinking skills, independent judgment, current technical knowledge and experience of MSO operations and workflow processes..

ESSENTIAL JOB FUNCTIONS:

• Interpret 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 data specifications, report submissions and timelines, etc.
• Develop, transform, edit, and maintain EZ-CAP, EZ-CARE, EZ-EDI, EZ-Net, and any additional system configuration framework and substructure; automate system workflows to promote operational efficiency.
• Perform analytical review and technical supports to diagnosis, define, track, and resolve critical 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.
• Perform independent system testing and validation, analyze outputs and results to allow for continuous improvement of the overall QA process for the MSO EZ-Suite system accuracy, integrity, and performance
• Collaborate with other MSO and PACE operational teams to understand workflow needs; design, develop and refine Work Queue processes in core systems to strengthen system enhancement activities including data mapping, system integration and workflow automation to meet and improve operation needs.
• Design, create and analyze statistical reports for other managed care operational teams to assist in the evaluation of business performance links to medical management services.
• Design and update training courses and materials; initiate training and retraining sessions to support department operations and ensuring users are properly updated to maximize system performance.
• Respond to system configuration flaws/errors and unresolved issues; analyze its criticality, and propose to MSO Director and EZCAP Product Development team for resolutions.
• Create and submit monthly data reports per health plans’ delegation agreement; reconcile eligibility, capitation, claims and authorization data discrepancies between contracted Health Plans, DHCS, CMS, and NEMS data.
• Responsible to generate and submit regular and ad-hoc reports to support manage care audit activities performed by various entities, including contracted Health Plans, DHCS, and CMS.
• Prepare regular statistical reports to support decision making in managed care business developments; respond to ad-hoc analysis and development requests under the direction of MSO Director as required 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.
• Five (5) 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;
• Minimum two (2) years system configuration experience in EZCAP and/or other system(s) or application(s) that integrate or interface with EZCAP.

• 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 independent problem solving skills across a wide variety of configuration and technical issues. Demonstrate willingness to make decision within Analyst’s scope of practice, exhibit sound and ethical judgment.
• Demonstrated ability to use Microsoft Access, Excel, Crystal Reports, and SQL Server Reporting Services.
• Minimum two (2) years working experience with Microsoft SQL programming and database development.
• Ability to self-manage in a detail-oriented environment. Willing to work after-hour and weekend as needed to perform task independently.
• 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 exempt position.

This is not an OSHA high-risk position.

I acknowledge that I have read, understood and accept this job description and am able to perform these essential job functions without restrictions. I also understand that it may be modified from time to time.

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).