Overview:
What you can expect!
Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!
Reporting to the Product System Configuration Supervisor, the Product Configuration Quality Analyst is responsible for ensuring the integrity of all claims system configuration created and maintained by the Product System Configuration team. The Product Configuration Quality Analyst audits claims system configured by the Application Architects and Analysts to ensure accurate adjudication of claims. Ensure all Business Rules are configured correctly in the claims system. Support testing efforts within an agile team and execute all levels of testing (System, Data validation, Integration and Regression). The Product Configuration Quality Analyst utilizes quality auditing tools, identifies trainings needs, and collaborates on effective and efficient methods for accurate and quality system configuration.
Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Additional Benefits:
Perks
IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.
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Competitive salary
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State of the art fitness center on-site
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Medical Insurance with Dental and Vision
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Life, short-term, and long-term disability options
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Career advancement opportunities and professional development
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Wellness programs that promote a healthy work-life balance
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Flexible Spending Account – Health Care/Childcare
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CalPERS retirement
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457(b) option with a contribution match
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Paid life insurance for employees
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Pet care insurance
Key Responsibilities:
- Audit team output, analyze and assess data reports, and validate system configuration accuracy against contract interpretation, business rules, and regulatory requirements. Ensure errors are corrected and escalated issues are resolved within a timely manner. Report findings and trends to leadership to further support requirements of accuracy and productivity.
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Partner with the Product System Configuration Supervisor to define and uphold quality standards for Application Architects and Analysts performing claims system configuration (test coverage, evidence standards, defect SLAs).
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Identify data integrity gaps, recommend process improvements, and flag training needs. Provide insights and feedback to Product System Configuration Supervisor.
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Generate and audit quality reports (billing/handling practices, adjudication results, exception trends). Trigger improvement actions with Analysts.
- Own the weekly review of the Claim Check Run Audit and reconcile issues/discrepancies.
- Conduct in-depth root cause analysis of claims and integrated system configuration related issues that arise from claims and integrated system errors. Classify defects (e.g., large/difficult/complex) using quantitative thresholds and clear language.
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Review regulatory guidelines to determine if claims system configuration updates are required. Identify, communicate, and present on impact of system enhancements or configuration changes on integrated systems and processes related to regulatory guideline updates. Track compliance in QA matrices.
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Partner in the development of configuration standards and best practice guides for maintaining efficiency, accuracy, automation and successful integration with internal and external systems and programs.
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Analyze and identify system configuration based on claims auto adjudication standard metrics and business operational requirements to identify systematic quality risks and control improvements.
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Own and maintain a library of system requirements, specifications, test cases, defect logs, and test results. Ensure traceability from requirement to test evidence.
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Own UAT (User Acceptance Testing) test plan preparation and test execution of product delivery initiative(s), crossing multiple applications.
- Develop and run automated test scripts and evaluate results.
- Work with Compliance teams to determine solutions to help comply with regulations, guidelines, and All Plan Letters (APLs). Attend DHCS meetings, as needed.
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Develop and maintain policies, procedures, and training guidelines on behalf of the Product System Configuration team.
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Assist with claims system configuration updates as needed.
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Facilitate audit meetings to keep discussions focused, productive, and aligned with objective.
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Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
Qualifications:
Education & Requirements
- Three (3) years of experience of auditing complex system configuration required
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Three (3) years of experience in Managed Care required
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Experience with claims review required
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Experience in claims analysis/auditing preferred
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Experience in major managed care system migration/implementation preferred
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Bachelor’s degree in IT or Business from an accredited institution required
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In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position: one (1) year of general healthcare experience plus three (3) years of claims analysis experience is required
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This experience is in addition to the minimum years listed in the Experience Requirements above
Key Qualifications
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Comprehensive knowledge and understanding of:
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Regulatory compliance and how configuration changes affect regulatory adherence
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CPT, HCPCS, Revenue, ICD-10 Coding rules and guidelines
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General managed care operations and delegated plan models
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CMS, DHCS, DMHC, NCQA rules and regulations
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Encounters, EDI submissions, provider web portals, integrated NCCI applications, and overall data mapping
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System and application process integrations and algorithms
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Medicare, Medi-Cal, and Covered California benefit structure and regulatory billing guidelines
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Medicare, Medi-Cal, and Covered California claim processing guidelines
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Relational database structure
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Testing and audit methodologies
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Strong skills in performing independent root cause analysis, developing test cases, and documenting findings
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Skills in Microsoft Excel, Access, and SQL applications
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Exceptional problem solving and critical thinking skills
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Strong presentation and written communication skills
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Ability to interpret regulatory changes and assess the need for configuration updates
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Ability to identify training gaps and advise leadership on quality trends
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Proven ability to:
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Operate as an independent reviewer and provide objective assessments under tight schedules
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Work independently and solve complex problems with little to no assistance
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Effectively manage competing priorities
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Ensure compliance and quality assurance standards are met
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Schedule may adjust based on business need which may include evenings, holidays, and weekends to ensure completion of projects and to meet deadlines
Start your journey towards a thriving future with IEHP and apply TODAY!
Work Model Location:
This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.)
Pay Range: USD $80,059.20 - USD $106,059.20 /Yr.
