Center of Excellence Specialist

The Center of Excellence Specialist is responsible for completing daily tasks within the center of excellence related to configuration of The Health Plan’s claims adjudication system. This position is highly focused on a team environment and will require collaboration between all areas of the business. 

Required:

1. High school diploma/equivalent and/or two years experience working in health care operations, or equivalent experience.
2. Strong organizational skills.
3. Highly motivated individual with the ability to work independently.
4. Excellent written and verbal communication skill.
5. Ability to prioritize work while following guidelines to achieve departmental goals.
6. Team oriented.
7. Critical thinking abilities with strong problem solving skills.
8. Strong attention to detail.

Desired:

1. College degree preferred.
2. Ability to make effective decisions without oversight.
3. Prior experience with claims processing systems.
4. Prior experience with benefit plans and/or provider pricing

Requirements:

1. Create and attach benefit plan templates for all lines of business.
2. Assist with attaching all other components, such as, COB, referral, and capitation, to Accounts.
3. Configure new provide contracts by writing Health Rules Language (HRL) based on contract terms.
4. Manage updates and/or annual configuration changes to provider contracts and benefit plans.
5. Collaborate with business leads when claims or provider issues fall to workbaskets.
6. Knowledge of claims processing edits and provider pricing in Source.
7. Provide assistance with message codes, code set, and fee schedule updates.
8. Support and maintain pricing and benefit configuration in current claims processing system as well as HRP.
9. Responsible for tracking and maintaining all configuration changes for audit purposes.

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