About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:
The Configuration Data Analyst is responsible for system configuration, implementations and conversions of SCFHP’s core systems. This position is responsible for the accurate interpretation and associated configuration of regulatory federal and state guidelines. along with business contractual agreements impacting benefits, contracts, millions of dollars in claims payment, case management, and/or grievance and appeals within core systems. The Configuration Data Analyst must have the ability to meet with internal and external business units and peers to gather requirements, independently analyze and mine data, draw sound conclusions, configure, test and implement the data structures that support SCFHP’s managed care information system (s) required to meet business needs, regulatory compliance, and vendor contractual obligations.

Day to Day:

Comprehensive understanding of capitation models in order to setup within our core system to support multiple delegate contracts averaging approximately 50 million dollars in monthly capitation payments, based on accurate setup and configuration.
Comprehensive understanding and ability to interpret simple and complex provider contracts and amendments in order to setup within our core system reimbursement for, but not limited to, hospitals, provider groups, ancillary providers averaging approximately 1 million dollars in weekly claim payments, based on accurate setup and configuration.
Comprehensive understanding and ability to interpret federal and state government (DHCS and CMS) guidelines, and eligibility and enrollment process in order to setup core systems for claims, case management, and grievance and appeals
Combine in-depth analysis of business unit requirements and comprehensive understand of core system capabilities, knowledge of claim processing, provider and vendor setup, authorizations and business processes in order to determine optimal core system setup to process claims, case management, and grievance and appeals with a high degree of accuracy and auto-adjudication.
Serve as a subject matter expert for multiple core systems including but not limited to QNXT, Essette, Beacon, Zipari, NetworX, Optum CES (Claims Editing System), etc.
roubleshoot small to large scale, basic to highly complex business and system production issues by thoroughly reviewing the issue, researching within internal and external documentation such as regulatory publications, and system user guides, performing analysis and critical thinking and testing in order to identify a root cause, document findings, and recommend solutions
Perform basic to highly complex system configuration and maintenance of system rules including but not limited to benefits, authorizations, contracts, fee schedules, DFRs, capitation, letter templates, etc. in order to fix production support issues, or support business needs and regulatory requirements in multiple system applications (such as QNXT, Essette, CES, etc.) for multiple lines of business.
Coordinate the loading, validation, and testing of third party software updates, rate changes, and code changes (CPT, Diagnosis, etc.) with business units and outside vendors, as needed.
Combine in-depth analysis of application configuration and data, information gathered through independent research, knowledge of system capabilities and interdependencies, and business processes to determine the best configuration in order to ensure overall accuracy and efficiency of system processing
Project and task management for small to large scale configuration projects including but not limited to: Attend meetings with business units to gather requirements, track actionable items, send regular communications, escalate identified risks, recommend, implement, and test configuration changes.

About You:

Bachelor’s Degree in Healthcare, Information Systems, or related field, or equivalent experience, training or coursework.
Experience in healthcare
Minimum three years of experience performing the above responsibilities or a minimum of 5 years Claims processing or application vendor experience in a managed care environment. Other additional qualifications may be used to substitute for a required experience.
Ability to understand technical requirements and configuration logic to ensure systems are properly configured to meet business needs.
Ability to meet deadlines, multi-task, troubleshoot, and problem-solve.
Must be able to utilize analytical skills to conceptualize and envision impact of changes, and recommend resolutions for business or system issues and gaps.
Ability to audit implemented changes to detect and resolve discrepancies to ensure work is accurate and precise.
General understanding of health care data sets such ICD9/10, CPT/HCPCs, provider contracts and benefits, authorizations, etc.

Please review the full job description on our Career’s page:

https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3096

Job Type: Full-time

Pay: $111,168.00 - $172,310.00 per year

Benefits:

Dental insurance
Employee assistance program
Flexible spending account
Health insurance
Life insurance
Paid time off
Retirement plan
Tuition reimbursement
Vision insurance

Work Location: Hybrid remote in San Jose, CA 95119

Santa Clara Family Health Plan

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