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Account & Provider Configuration Analyst - Health Plan Operations

Company: Fallon Health
Location: Worcester
Posted on: April 18, 2019

Job Description:


* Printing of routed sponsor benefit change requests out of Crystal Enterprise

* Creation of various lines of New Business upon elected effective date within the QNXT application

* Processing of various lines of business upon anniversary date within the QNXT application inclusive of configuration and assignment of rate codes, copay and coinsurance groups

* Creation of Org Policy and all applicable attribute information

* Configuration and requests of sponsor ID cards

* Request and ordering of all benefit related documents and ensuring such is done in SLA timeframes, in turn using these documents to configure PCS benefits

* Quality Control on all implemented data

* Maintenance of productivity logs

* Maintenance of all assigned fulfillment codes

* Processing of all Termination and Reinstatement requests for various lines of business received and ensuring this information is referenced in QNXT and Avenue applications along with updating fulfillment information

* Initial set up of rate table within QNXT Sponsor Module

* Processing of Territory, Demographic, tiers, billing, office locations, contract entities and Probationary Period changes in applicable systems

* Coding and Processing of Renewing As Is sponsor information routed from the sales team

* Configuring benefits within the PCS application across all lines of business within SLA s

* Data entry of standard provider information into QNXT system and other related databases according to established departmental standards for accuracy and timeliness.

* Determine completeness of forms prior to entry. Research any misleading or missing data fields and escalate any unresolved issues to Manager

* Work with Provider Relations/ Contract Managers on identified discrepancies

* Research and update all provider NPI, Medicaid or Medicare numbers as providers are enrolled into QNXT

* Responsible for ensuring edits and call tracking cases are completed within applicable SLA on a timely basis

* Fully support internal audits and respond timely to any resulting action plans

* As an analyst, it is expected you will explore process improvement opportunities as well as mentor new and current team members

* Expedite implementation delays and escalate issues to upper management as appropriate

* Strictly observe the Fallon Health policy regarding confidentiality of member or provider information.

* Flag all contracted providers to display or print in the directory as identified on the distribution notification forms.

* Researching daily ID card errors

* Ensures all Caremark member inaccuracies are resolved in a timely manner

* Working daily Clarity Material errors

* Working daily Data Integrity kick-outs in the QNXT system

* Working edits pertaining to Medicare supplement contracts

* Working 1099 issues along side the finance department to ensure accuracy of the IRS file

* Work call tracking cases in a timely and accurate manner

* Assisting in sales/Customer service requests for ID card/materials mailings

* Assignment of fulfillment codes for new or updated product configurations

* New Business and Renewal sales support contact

* Supplying assigned code information to various departments to assist in member grievances or research

* Requesting of Caremark Pharmacare codes

* Partaking in miscellaneous projects at Fallon Health

* Participate in research and testing of system application accuracy to resolve processing problems.



College Degree or equivalent experience


* QNXT experience preferred, 3-5 years Healthcare

* Basic analytical & quantitative skills to identify member or provider downstream impact as a result of invalid entry/configuration

* Intermediate MS Office experience with an emphasis on MS Excel and Access skills in order to manipulate and communicate data

* Organizational skill with the ability to effectively manage multiple projects simultaneously

Fallon Health is an equal opportunity employer. It is very important for us to maintain a consistant hiring process for every candidate. In addition, we are also a government contractor with requirements to report on our Affirmative Action planning. To that end, we require everyone to apply online.

If you do not have access to a computer or need assistance completing the application process, please contact Human Resources at 1-508-368-9893 (TRS 711).

Keywords: Fallon Health, Worcester , Account & Provider Configuration Analyst - Health Plan Operations, Healthcare , Worcester, Massachusetts

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