Functional knowledge:- Utilization management and prior authorization - authorization lifecycle, medical necessity review, inpatient and outpatient requests, determinations, appeals and turnaround obligations.
- Care and disease management - case creation and stratification, care plans, assessments, member outreach, vendor referral.
- Benefit configuration - how program and product benefits map to purchasing groups, including base and buy-up tiers.
- Membership and eligibility - Commercial, Federal Employee Program and Medicare Advantage, and how coverage periods drive case and authorization behavior.
- Quality and regulatory - HEDIS, NCQA accreditation and Star ratings, and how application data supports them. CMS interoperability awareness an advantage.
- Correspondence - member and provider letter generation and the regulatory timing attached to it.
Platform experience:- Highly desirable - Cognizant CareAdvance (care and utilization management) and CareAdvance Provider / E-Referral (provider prior authorization portal) in a payer environment.
- Also relevant - TriZetto CareAdvance, Facets, QNXT, HealthEdge GuidingCare, ZeOmega Jiva, Altruista, or an equivalent in-house UM/CM system.
- Transactions and interfaces - EDI X12 278 authorization request and response; 834, 837 and 835 useful. FHIR and clearinghouse integration such as Availity an advantage.
Technical skills:- SQL - confident writing queries against Oracle and SQL Server to validate requirements, trace a record and confirm a defect. A working requirement, not a nice-to-have.
- Data structures - able to read a data model and follow a field from source file through staging to the consuming application.
- Tooling - JIRA, Confluence or SharePoint, TOAD or SQL Developer. ETL concepts (Informatica or similar) and batch scheduling exposure useful.
- Testing - test case design, UAT coordination and defect triage. Postman or SOAP UI for web service validation an advantage.
Certifications: IIBA CBAP or ECBA; PMI-PBA; CSPO. AHIP or AHM 250 payer certification desirable
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