Analyst

Key Responsibilities

• Configure, maintain, and support Facets Pricing components including Fee Schedules, Pricing Rules, Provider Contracts (Professional, Institutional, Ancillary), Multiple Procedure Pricing (MPP), Modifiers, Global Periods, and Carve-outs. Ensure accurate implementation aligned with contractual agreements.
• Configure pricing logic for Professional, Facility, and Ancillary claims. Implement methodologies including DRG, APC, Per Diem, Case Rates, and Fee-for-Service. Translate business requirements into system configuration.

Medical Policy Configuration & Support

• Interpret and implement medical policies into Facets.
• Configure edits and ensure alignment with clinical guidelines.
• Support updating quarterly code new code update in facets.

ITS Configuration

• Configure and support ITS (Inter-Plan Teleprocessing System) scenarios.
• Ensure compliance with BlueCard guidelines. Troubleshoot ITS claims issues and validate Host/Home processing.

Workflow

• Configure override, pend in workflow module in facets

Claims & Testing

• Analyze and troubleshoot configuration issues related to benefit and pricing.
• Perform Unit, SIT and UAT testing.
• Validate outcomes against contracts, benefits, and policies.

Required Qualifications

• 5+ years of experience in Facets Benefit, Pricing or workflow.
• Strong expertise in pricing modules, medical policy, ITS, and workflow module.
• Solid understanding of US healthcare claims.

Key Skills

Analytical thinking, attention to detail, strong communication, and stakeholder management.

Work Location

Onshore (USA-based)

Summary

This role ensures implementing correct configuration design by integrating facets benefit, pricing & workflow modules to meet the business requirement.