Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Configuration Analyst, specializing in claim editing software, is responsible for configuring system edits, and rules and workflows to ensure efficient claims processing. This role will work closely with stakeholders to understand and apply medical claim coding, policies, and provider contract nuances into system configurations. The ideal candidate should have strong technical knowledge, be detail-oriented, and possess experience in healthcare claims processing, including claim editing software configuration and medical coding

Job Duties/Responsibilities:

• Configure system edits and rules within claim editing software to meet business needs and ensure compliance with medical claim coding guidelines, policies, and provider contract requirements.
• Interpret and implement medical claim coding requirements (e.g., ICD-10, CPT, HCPCS codes) into system configurations to ensure accurate claim editing and processing.
• Integrate provider contract terms into the configuration of payment rules, edits, and exceptions for claims processing.
• Test and validate configurations to ensure accurate functionality, compliance, and alignment with coding rules, payer policies, and contractual obligations.
• Maintain and update configuration settings, workflows, and business rules to reflect changes in medical claim coding, regulatory updates, and provider contracts.
• Provide support for troubleshooting and resolving issues related to configuration, coding, or payment discrepancies.
• Document configuration specifications, clearly outlining business rules, coding requirements, and provider contract details for system users and stakeholders.
• Ensure that all configurations adhere to claim editing software best practices and regulatory requirements, including compliance with payer policies and contract terms.
• Participate in regular meetings with stakeholders to report progress, resolve issues, and identify areas for improvement in claim processing workflows.

Job Requirements:

Experience:
• Required: Minimum of 2 years of hands-on experience in medical claim configuration, claim editing software configuration, or similar healthcare claims processing systems.
• Preferred: 3+years of hands-on experience in medical claim configuration, claim editing software configuration, or similar healthcare claims processing systems.

Education:
• Required: High School Diploma or GED.
• Preferred: Bachelor's degree or 3+ years hands-on experience in medical claim configuration, claim editing software configuration, or similar healthcare claims processing systems.

Training:
• Required: None
• Preferred: None

Specialized Skills:
• Required:

• Strong understanding of medical claim coding systems (ICD-10, CPT, HCPCS) and experience applying these codes in claim edits and payment processing.
• Familiarity with payer policies and provider contract terms and how they impact claim processing.
• Experience in configuring business rules, workflows, and edits in complex healthcare enterprise systems.
• Proficient in configuring claim editing software and understanding the nuances of payment edits and adjustments.
• Knowledge of medical coding, billing, and claim processing guidelines.
• Experience working with provider contracts to configure payment rules and system edits.
• Strong problem-solving abilities with a focus on accuracy and detail in claim editing.
• Excellent communication skills to collaborate with both technical and non-technical teams.
• Ability to interpret complex policies, medical codes, and contract terms and integrate them into system configurations.
• Report Analysis skills: Proficiency in data analysis and reporting tools such as SQL, Excel, or other healthcare-specific tools.
• Proficiency in Microsoft programs. Intermediate or advanced level proficiency with Microsoft Excel, Word, and PowerPoint.

Licensure:
• Required: None
• Preferred:

Other:
• Required: None

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $64,384.00 - $96,577.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com.