Adjudication Services Technical Analyst II

MedImpact Healthcare Systems   •  

San Diego, CA

Industry: Healthcare IT


5 - 7 years

Posted 341 days ago


Adjudication Services Technical Analyst II

If you’re interested in a career within a customer-focused, team-oriented environment that rewards innovation, quality, integrity and collaboration, MedImpact Healthcare Systems, Inc. welcomes your application. MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Position Summary

The Adjudication Services Technical Analyst II performs claims adjudication testing and validation by developing and executing test plans, analyzing claims adjudication results in a test environment, validating benefits and pharmacy network configurations, and recommending adjudication changes/enhancements and documentation as to deliver accurate Point of Service (POS) results. This role collaborates with multiple business units, including Information Technology, and with internal customers to develop accurate coding specifications, ensure ongoing accuracy of adjudication configurations, and pre-production quality control of POS and systems changes.

The position also adheres to strict procedural and quality standards, including thorough and accurate documentation, testing protocols, and claims analysis while relying on experience, judgment, business applications & systems knowledge, and technical skill to plan and accomplish goals.  A wide degree of creativity and latitude is expected with the extent of supervision ranges from moderate, to minimal, to independent based upon demonstrated skill and performance level as defined for the position. 

Essential Functions and Responsibilities include the following. Other duties may be assigned.

  • Works with business partners to develop and execute test plans for claims adjudication enhancements to support the core business logic and rules as well as providing user education and FAQ development
  • Writes and maintains detailed documentation of testing & validation activities including sponsor specifications, expected outcomes, testing methodology & processes, test results, recommendations, version control, and configuration design
  • Analyzes claims adjudication results and identifies discrepancies, inaccuracies, anomalies, and unexpected consequences
  • Makes recommendations and develops solutions and education materials to enhance the accuracy of POS system changes and configuration setups
  • Partners withInformation Technology Data Programmers and Analysts in development of advanced/complex POS system programming
  • Collaborates with Operations staff to ensure that sponsor expectations are achieved through up-front clarification of specifications, design reviews, and development of best practice coding guidelines
  • Advises and recommends configuration models to Benefits and Pharmacy Network staff
  • Utilizes planning, prioritizing, and organizational skills to ensure timely deliverables, high levels of quality, and efficient use of resources to achieve claims adjudication accuracy
  • Provides support to internal staff as an SME on POS adjudication capabilities through a queue
  • If documentation is insufficient to answer a client need, creates test claims to validate functionality within POS
  • Views system enhancements in light of the potential to increase claim rejections and works with appropriate parties to provide notice and outreach to lessen the impact of proposed change while tracking the effort for internal planning purposes
  • Provide criteria to internal contacts and/ or directly to pharmacy to assist with claim format issues causing rejections
  • Maintains commitment to operational goals in the face of obstacles
  • Collaborates and cultivates positive relationships with internal and external customers through delivery of sustainable, measurable, accurate, reliable, and timely results that meet or exceed customer expectations
  • Promptly responds to service failures, resolves issues, and escalates concerns as appropriate
  • Actively participates in continued professional development to stay up-to-date on the latest technical enhancements, NCPDP system change requirements and quality management best practices
  • Based upon career path level, completes special projects and assignments (such as leading design reviews, gathering technical requirements, creating statements of work (SOW) for complex technical projects, mentoring/training staff, etc.)
  • Demonstrate ability to appear for work on time, follow directions from a supervisor, interact well with co-workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment
  • Mentor and train team members and peers
  • Develops efficient SQL queries to research, gather data and identify solutions

Education and/or Experience                                                    

For consideration candidates will need a Bachelor's degree (B.A.) from four-year College or university and five (5) to eight (8) years of benefits coding or configuration experiencerequired in Pharmacy Benefit Management (PBM), Pharmacy systems management and claims processing, or related ManagedHealthcareexperience, or an equivalent combination of education and job related experience.  Experience must include a minimum of three (3) years of testing experience.  

Computer Skills

  • Intermediate to advanced knowledge of MS Office / Word, PowerPoint, and Outlook
  • Advanced knowledge of MS Excel and working knowledge of key business applications such as SQL queries, Oracle forms, Golden 32, MedAccess, MedAccess Classic, MS Access, MedOptimize, Visio, or others as applicable to the role
  • Ability to run SQL queries and scripts