Auditor, Benefit System/Configuration Quality
Company Name:
Test Company KP
Title: Auditor, Benefit System/Configuration Quality
Location: Portland, OR
Configuration Quality Auditor exists to ensure the integrity of configuration for the organization through verification of the accuracy of data-entered information and system interfaces (BETS, CM, DIAMOND) in accordance with departmental policy and procedures. The position will monitor and validate the accuracy of mappings for Benefit Translator; Mapping for Diamond Benefit Package creation and Diamond Benefit Rule configuration. The auditor must be thoroughly familiar with BETS and Diamond application configuration, provider contacts, and benefits. The position requires research, problem resolution and specialized knowledge in the areas of provider contracts (both contracted and non-contracted), benefit and general configuration, authorizations, group and member structures, as well as system interfaces and platforms. The auditor will provide education and feedback to staff involved in the related processes.
Essential Functions:
- Measures personal & team results against an internal standard of excellence.
- Partners with the Benefits Administration Team to articulate new benefits; validate BETS & Diamond configuration & ensure synchronization between BETS, Diamond & HealthConnect applications.
- Performs validation of configuration activities (which may include all or some of the following: institutional & professional provider contracts, benefits, authorizations, and/or claims/general configuration (i.e. system edit rules, fee schedules).
- Maintain auditing tools, databases, & daily, monthly & quarterly reports for the purpose of monitoring workflows, accuracy & integrity of audits & team/departmental performance metrics.
- Ensure that required audit results are reported, produced in a readable format & made available to the configuration staff & other personnel as required.
- Validate configuration test claims to ensure accuracy of data loaded into the Diamond system & any other interface system setups.
- Write & generate ad-hoc validation queries & claims impact reports & compile reconciliation statements.
- Assists in establishing, & documenting policies & procedures in support of standardized & accurate configuration.
- Proactively identify, through auditing & internal reporting, negative & positive trends & initiate recommendations for change.
- Assist with the preparation of external audits & internal audits as defined by audit controls, as needed (i.e. SOX, NCO, Internal Audit Service).
- Thinks of ways to improve results, communicates these to
manager
/supervisor, peers & team members.
- Demonstrate excellent verbal, written, & interpersonal communication skills & communicates thoughts clearly & concisely.
- Provides
expert
knowledge, impact analysis & recommendations related to configuration design & understanding impacts of benefit data / provider contract data on all
systems
that require benefit data/provider contract data & frequently act as a liaison, problem solver & facilitator.
- Able to interact with various levels of professionals.
- Develops processes to analyze, design, configure, code & QA detailed benefit designs & provides assistance to all departments on benefit coding issues.
- Ensures correct interpretation & definition of benefits.
- Asks direct questions & listens carefully to responses, restating to clarify understanding.
- Negotiates conflict & difficult situations with tact & candor.
- Identifies & seeks approval for key actions necessary to remediate all problems/issues & makes recommendations to mgmt on steps to ensure product is delivered on time within specifications.
- This job description is not all encompassing.
Qualifications:
Basic
Qualifications:
Experience
- Minimum three (3) years of benefit configuration / coding experience.
- Minimum of five (5) years in healthcare or managed care.
- Four (4) plus years of relevant analytical/business system support experience.
- Significant experience in documentation, research and reporting required.
Education
- Bachelor's degree in information systems, business or health care administration, or other related field, or equivalent work experience.
Licenses, Certifications, Registrations
- N/A.
Additional Requirements:
- Expert knowledge in Claims/provider contracts/member plan benefits in Diamond.
- Demonstrated competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database is required.
- Knowledge of state and federal regulations.
- Strong critical thinking and analysis skills; verbal and written communications, and interpersonal interactions (e.g. partnering, conflict
management
, consulting, etc.).
- Advanced proficiency in Microsoft Excel.
- Intermediate proficiency in Microsoft Access and Query Tools.
- Basis proficiency in Statistical analysis.
- Demonstrated competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database is required.
- Expert knowledge in Claims and provider contracts in the appropriate Regional Claims system.
- Thorough knowledge of benefits, benefit administration and health care delivery from either/both a payor or provider perspective, along with insurance industry
practices
and systems.
- Understanding of relational databases.
- Familiarity with relevant service delivery/insurance/finance business units.
- Proven team skills including the following attributes: efficient, collaborative, candid, open, and results-oriented.
- Process flow and desk procedure development and documentation.
- Development of business specification documentation.
- Excellent interpersonal, communication, and listening skills are required.
- Proven ability to conduct, interpret and communicate quantitative/qualitative analysis.
- Influences others regarding existing concepts, processes and/or methodology.
- Communicates project/task purpose and connects it to goals of group/unit of operation and member/customer needs.
- Ability to support formal training programs for system users.
- Provides professional/technical guidance to team members.
- Networks with senior internal and external personnel in own area of expertise.
- Thorough knowledge of policies, practices and systems.
- Complete understanding and application of principles, concepts, practices, and standards.
- Full knowledge of industry practices.
- Broad application of principles, theories, and concepts in applicable discipline, plus working knowledge of other related fields.
- Requires significant analysis to develop solutions for complex problems.
Preferred
Qualifications:
- Five (5) years of analytical experience at KPNW preferred.
- Minimum four (4) years of experience of related Health Plan, Medical Group, hospital or insurance analytical and/or consulting experience preferred.
- Experience with Center for Medicaid and Medicare (CMS) regulatory guidelines preferred.
- Bachelor's degree preferred.
- Expertise in assigned business unit (service delivery, insurance, finance) preferred.
- EPIC Benefit Engine, Tapestry AP claims or Diamond claims desirable.
- General knowledge of BETS, CM and Diamond systems preferred.
- Specific and broad knowledge of KPNW operations and relevant business systems and data sources such as KP HealthConnect Hyperspace and Clarity preferred.
- Assesses information to identify the best solution preferred.
Salary Range:
$66,740 - $91,460Estimated Salary: $20 to $28 per hour based on qualifications.
Test Company KP
Title: Auditor, Benefit System/Configuration Quality
Location: Portland, OR
Configuration Quality Auditor exists to ensure the integrity of configuration for the organization through verification of the accuracy of data-entered information and system interfaces (BETS, CM, DIAMOND) in accordance with departmental policy and procedures. The position will monitor and validate the accuracy of mappings for Benefit Translator; Mapping for Diamond Benefit Package creation and Diamond Benefit Rule configuration. The auditor must be thoroughly familiar with BETS and Diamond application configuration, provider contacts, and benefits. The position requires research, problem resolution and specialized knowledge in the areas of provider contracts (both contracted and non-contracted), benefit and general configuration, authorizations, group and member structures, as well as system interfaces and platforms. The auditor will provide education and feedback to staff involved in the related processes.
Essential Functions:
- Measures personal & team results against an internal standard of excellence.
- Partners with the Benefits Administration Team to articulate new benefits; validate BETS & Diamond configuration & ensure synchronization between BETS, Diamond & HealthConnect applications.
- Performs validation of configuration activities (which may include all or some of the following: institutional & professional provider contracts, benefits, authorizations, and/or claims/general configuration (i.e. system edit rules, fee schedules).
- Maintain auditing tools, databases, & daily, monthly & quarterly reports for the purpose of monitoring workflows, accuracy & integrity of audits & team/departmental performance metrics.
- Ensure that required audit results are reported, produced in a readable format & made available to the configuration staff & other personnel as required.
- Validate configuration test claims to ensure accuracy of data loaded into the Diamond system & any other interface system setups.
- Write & generate ad-hoc validation queries & claims impact reports & compile reconciliation statements.
- Assists in establishing, & documenting policies & procedures in support of standardized & accurate configuration.
- Proactively identify, through auditing & internal reporting, negative & positive trends & initiate recommendations for change.
- Assist with the preparation of external audits & internal audits as defined by audit controls, as needed (i.e. SOX, NCO, Internal Audit Service).
- Thinks of ways to improve results, communicates these to
manager
/supervisor, peers & team members.
- Demonstrate excellent verbal, written, & interpersonal communication skills & communicates thoughts clearly & concisely.
- Provides
expert
knowledge, impact analysis & recommendations related to configuration design & understanding impacts of benefit data / provider contract data on all
systems
that require benefit data/provider contract data & frequently act as a liaison, problem solver & facilitator.
- Able to interact with various levels of professionals.
- Develops processes to analyze, design, configure, code & QA detailed benefit designs & provides assistance to all departments on benefit coding issues.
- Ensures correct interpretation & definition of benefits.
- Asks direct questions & listens carefully to responses, restating to clarify understanding.
- Negotiates conflict & difficult situations with tact & candor.
- Identifies & seeks approval for key actions necessary to remediate all problems/issues & makes recommendations to mgmt on steps to ensure product is delivered on time within specifications.
- This job description is not all encompassing.
Qualifications:
Basic
Qualifications:
Experience
- Minimum three (3) years of benefit configuration / coding experience.
- Minimum of five (5) years in healthcare or managed care.
- Four (4) plus years of relevant analytical/business system support experience.
- Significant experience in documentation, research and reporting required.
Education
- Bachelor's degree in information systems, business or health care administration, or other related field, or equivalent work experience.
Licenses, Certifications, Registrations
- N/A.
Additional Requirements:
- Expert knowledge in Claims/provider contracts/member plan benefits in Diamond.
- Demonstrated competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database is required.
- Knowledge of state and federal regulations.
- Strong critical thinking and analysis skills; verbal and written communications, and interpersonal interactions (e.g. partnering, conflict
management
, consulting, etc.).
- Advanced proficiency in Microsoft Excel.
- Intermediate proficiency in Microsoft Access and Query Tools.
- Basis proficiency in Statistical analysis.
- Demonstrated competency in medical coding, medical terminology, claims processing, logical thinking and understanding of relational database is required.
- Expert knowledge in Claims and provider contracts in the appropriate Regional Claims system.
- Thorough knowledge of benefits, benefit administration and health care delivery from either/both a payor or provider perspective, along with insurance industry
practices
and systems.
- Understanding of relational databases.
- Familiarity with relevant service delivery/insurance/finance business units.
- Proven team skills including the following attributes: efficient, collaborative, candid, open, and results-oriented.
- Process flow and desk procedure development and documentation.
- Development of business specification documentation.
- Excellent interpersonal, communication, and listening skills are required.
- Proven ability to conduct, interpret and communicate quantitative/qualitative analysis.
- Influences others regarding existing concepts, processes and/or methodology.
- Communicates project/task purpose and connects it to goals of group/unit of operation and member/customer needs.
- Ability to support formal training programs for system users.
- Provides professional/technical guidance to team members.
- Networks with senior internal and external personnel in own area of expertise.
- Thorough knowledge of policies, practices and systems.
- Complete understanding and application of principles, concepts, practices, and standards.
- Full knowledge of industry practices.
- Broad application of principles, theories, and concepts in applicable discipline, plus working knowledge of other related fields.
- Requires significant analysis to develop solutions for complex problems.
Preferred
Qualifications:
- Five (5) years of analytical experience at KPNW preferred.
- Minimum four (4) years of experience of related Health Plan, Medical Group, hospital or insurance analytical and/or consulting experience preferred.
- Experience with Center for Medicaid and Medicare (CMS) regulatory guidelines preferred.
- Bachelor's degree preferred.
- Expertise in assigned business unit (service delivery, insurance, finance) preferred.
- EPIC Benefit Engine, Tapestry AP claims or Diamond claims desirable.
- General knowledge of BETS, CM and Diamond systems preferred.
- Specific and broad knowledge of KPNW operations and relevant business systems and data sources such as KP HealthConnect Hyperspace and Clarity preferred.
- Assesses information to identify the best solution preferred.
Salary Range:
$66,740 - $91,460Estimated Salary: $20 to $28 per hour based on qualifications.
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