Benefit Configuration Analyst

Collects and analyzes data to evaluate operational obstacles which include revenue and compliance issues, and makes recommendations to resolve issues in a timely matter. Uses the medical classification system to design the benefit packages with proper ICD-9, CPT-4, HCPCS for configuration into the Peradigm System. Disseminates benefit determinations to key stakeholders administering benefits (health services, configurations, etc.) throughout the organization. Serves as an integral role in the testing, analysis and benefit configuration of new and existing plans.

Essential Functions:
  • Reviews, analyzes and translates diagnostic procedural phrases into coded form.
  • Updates and maintains adjudication system with defined code sets in logical order.
  • Coordinates with internal operations departments to ensure data accuracy.
  • Produces reports from the Peradigm System to analyze necessary modifications to codes sets, BRULES and MEDEFs.
  • Creates testing scripts for new and existing plans.
  • Assists in the on-going evaluation of the benefit configurations within the Peradigm System for new and existing benefit plans.
  • Documents the configuration of new plans as well as changes in existing plans.
  • Provides feedback to stakeholders regarding feasibility and requirements for enhancements to benefit configuration.
  • Provides research assistance for the resolutions of benefit issues.
  • Serves as a liaison of benefit configuration to external departments.
  • Collects and analyzes data to evaluate operational difficulties and makes recommendations to solve problems.
  • Performs special projects as needed.
Additional Responsibilities:
    Candidate Education:
    • Required An Associate's Degree in CIS, BIS, or coding
    • Required or equivalent work experience
    Candidate Experience:
    • Required 2 years of experience in medical coding and configuration
    Candidate Skills:
    • Intermediate Other Applies coding knowledge to ascertain codes sets for each service
    • Intermediate Other Ability to break procedures down at a granular level and organize data in a logical manner
    • Intermediate Other Ability to conduct Internet research to update code sets
    Licenses and Certifications:
    • Preferred
    • Preferred RMC certification
    Technical Skills:
    • Required Intermediate Peradigm (Diamond)
    • Preferred Intermediate Microsoft Access
    • Preferred Intermediate SQL Server System
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft Outlook
    • Preferred Intermediate Other Knowledge of organization of data within medical adjudication systems
    Languages:

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.