Configuration Pricing and Quality Analyst

COMPANY OVERVIEW:

HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences.

We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously.

We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish.

PURPOSE AND SCOPE:

We are seeking a highly skilled professional with expertise in system pricing configuration, Payer Compass software, and a strong understanding of Medicare, Medicaid, and commercial pricing. This role requires an individual who can leverage their knowledge to drive quality and configure pricing models within the healthcare payer environment. The ideal candidate will have hands-on experience with pricing configurations, payer systems, and healthcare compliance. The CPQA will have direct contact with Payer Compass to validate, review and discuss quality related items.

PRINCIPAL RESPONSIBILITIES AND DUTIES:

System Pricing Configuration:

Develop, implement, and maintain pricing configuration models for various payer categories (Medicare, Medicaid, Commercial)

Configure pricing systems to ensure accurate reimbursement and compliance with contractual terms

Collaborate with cross-functional teams to implement system changes and updates to pricing models

Analyze and resolve pricing discrepancies, providing recommendations for improvements

Build robust audit and scheduling tools to manage pricing updates and the accuracy of those updates including, but not limited to, specific code pricing, fee schedule accuracy and appropriate claims edits

Payer Compass Expertise:

Utilize Payer Compass to configure pricing systems and manage contract rates across different payer categories

Ensure proper integration of Payer Compass into other payer systems for accurate pricing and payment

Troubleshoot and resolve issues related to Payer Compass functionality, system configuration, and data accuracy

Day-to-day oversight of Payer Compass outputs feeding claims pricing

Medicare, Medicaid, and Commercial Pricing Knowledge:

Apply in-depth knowledge of Medicare, Medicaid, and Commercial payer systems, including reimbursement policies, regulations, and rate structures

Monitor and analyze industry trends and regulatory changes related to Medicare, Medicaid, and Commercial insurance, ensuring compliance with federal and state guidelines

Provide strategic insights and recommendations on pricing models and reimbursement strategies based on payer-specific needs

Quality Assurance and Configuration Testing:

Conduct thorough testing of pricing configurations to ensure accuracy, functionality, and compliance with payer contracts and regulations

Collaborate with IT and other departments to ensure system functionality aligns with business requirements and service level agreements (SLAs)

Ensure ongoing system quality by monitoring pricing performance, identifying areas for improvement, and driving continuous improvement efforts

Collaboration and Communication:

Work closely with internal teams, including finance, operations, IT, and compliance, to ensure pricing strategies align with organizational goals and regulatory requirements

Effectively communicate pricing changes, system updates, and compliance updates to relevant stakeholders

Documentation and Reporting:

Maintain detailed documentation on pricing configurations, system settings, and any changes made to payer-specific models

Generate and analyze pricing reports to provide insights into payer performance and profitability

General Responsibilities:

Assist in audit preparation and regulatory reporting, ensuring all pricing data is accurate and compliant

Implement testing plans to ensure quality configuration of benefit plans, fee schedules, and provider contract pricing

Evaluate fee schedule source documents from CMS or other applicable data sources, analyze reimbursement methods, develop, and load schedules to support proper payment based on provider contractual agreements

Review and analyze provider contracts, determine reimbursement structures and payment terms, and create contract templates in HxPro

EDUCATION, EXPERIENCE AND REQUIRED SKILLS:

8 + years pricing configuration experience

Preferred 5+ years working with Payer Compass software

Knowledge of Health Care industry including medical terminology, claims processing guidelines, industry vernacular, code sets associated with system configuration and basic billing knowledge

Knowledge of managed care health insurance programs with an emphasis on CMS knowledge. Medicare Advantage experience is preferred

Knowledge of healthcare reimbursement models, including fee-for-service, bundled payments, and value-based care

Proven experience in quality assurance, testing, and configuration management in a healthcare payer environment. Advanced skills in MS Office products including Outlook, Word, Excel, MS teams and SharePoint

Experience with CMS regulations, pricing methodologies, audit processes and expectations

Intermediate to advanced experience using a relational database and Microsoft SQL Server Management Studio knowledge to retrieve and analyze data

Successfully navigate and master proprietary software programs

Extensive knowledge of CPT, HCPCS, and ICD-10

Excellent problem-solving skills and attention to detail

Strong communication and interpersonal skills with the ability to collaborate effectively with cross-functional teams