Full Job Description
About this role:
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
**This role is open to California residents only.**
ESSENTIAL FUNCTIONS
Job Function & Responsibilities
• Configuration Design & Build
o Translate business requirements into accurate HRP configuration across benefits, provider contracts, pricing rules, accumulators, claims edits, and product variations.
o Build and maintain benefit structures, benefit dictionaries, coverage tiers, copays, deductibles, and EOC/Evidence of Coverage mappings.
o Configure provider reimbursement logic including fee schedules, capitation, FFS, value-based rules, and DOFR constructs.
o Apply HRP tools (HealthRules Language™, Designer/Manager) to model complex logic without custom code.
• Testing & Validation
o Develop detailed test scenarios and execute UAT for configuration changes, ensuring financial and non-financial accuracy.
o Perform impact analysis for new configuration, regulatory updates, and system enhancements.
o Support production validation, post-release monitoring, and defect remediation with clear traceability to requirements.
• Troubleshooting & Root-Cause Analysis
o Investigate adjudication issues, benefit discrepancies, and pricing errors using structured analysis.
o Identify root causes across configuration, requirements, provider contracts, and system logic.
o Document findings and collaborate with cross-functional teams to implement corrective actions.
• Regulatory & Compliance Alignment
o Ensure configuration adheres to California regulatory requirements, including Medi-Cal benefit structures, payment rules, and policy updates.
o Maintain awareness of state and federal regulatory changes and assess configuration impacts.
• Cross-Functional Collaboration
o Partner with Operations, Network, Product, Compliance, and QA to ensure configuration aligns with business goals and regulatory needs.
o Participate in requirements sessions, benefit design reviews, contract updates, and system enhancement planning.
o Provide subject-matter expertise during audits, regulatory reviews, and cross-departmental initiatives.
• Documentation & Governance
o Maintain clear documentation of configuration decisions, logic, test cases, and validation results.
o Support configuration governance processes, including standards, naming conventions, and version control.
o Contribute to playbooks, SOPs, and best practices for configuration quality and release readiness.
• Continuous Improvement
o Identify opportunities to streamline configuration processes and reduce defects.
o Support HRP upgrades, parallel testing, cutover readiness, and post-go-live stabilization activities.
o Mentor junior analysts and contribute to team knowledge development. Any other duties assigned
MINIMUM QUALIFICATIONS
Education & Experience:
• High School Graduate or General Education Degree (GED)
• 2-5 years of hands-on configuration experience, including at least 2 years working with HRP, across benefits, provider contracts, pricing rules, and claims edits.
• California health plan experience with strong understanding of state-specific requirements; Medi-Cal preferred.
• Strong understanding of payer operations, claims adjudication, reimbursement methodologies, and regulatory constructs.
• Proficiency with HRP components such as HealthRules Language™, Designer/Manager (Answers/Connector a plus).
• Experience with healthcare EDI and code sets (HIPAA 837/835/834/270/271; ICD-10, HCPCS, CPT, DRG, APC, NDC).
• Demonstrated ability to translate complex business requirements into accurate configuration with documented rationale.
• Strong skills in test planning, UAT execution, impact analysis, and production validation.
• Excellent communication, analytical, and documentation skills.
• Ability to work independently and collaboratively in a remote, fast-paced environment.
KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
• Bachelor's degree
• Three plus years' experience with Medi-Cal guidelines
• Three plus years' experience data analytics and reporting
• Two years' experience in a Supervisor, Lead, Trainer, Quality Assurance or Auditor role
• Three years' experience using analytical thinking skills and demonstrated ability to exercise sound judgment when making decisions
• Experience with Medi-Cal managed care contract constructs and operational requirements.
• Exposure to broader HRP functional areas (enrollment, billing, provider, finance, medical management/GuidingCare).
• Experience with HRP implementations, conversions, or major upgrade cycles.
• Familiarity with configuration governance frameworks and release management processes.
Technology & Software Skills: Advanced computer skills in MS Office products.
Certifications & Licenses: None
Competency Statements
• Business Acumen - Ability to grasp and understand business concepts and issues.
• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.
• Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
The estimated pay range for the position is:
$100,000.00 - $150,000.00
The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.
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