Claims Software System Configuration Tester

Assists in the development of new product/client implementation regarding managed care operational initiatives/enhancements and strategic initiatives on behalf of the providers affiliated with Advocate Health Care (AHC) and non-affiliated PHOs. The Software System Configuration Tester validates department effectiveness by developing an audit program to verify individuals for industry standards for data, financial and procedure accuracy. Assist in testing and implementation of a process for automation of claims/system setup process.

Major Responsibilities:

• Develop, lead, and implement auditing policies for financial, data and procedure accuracy.
• Participates in the operational review process for System Reimbursement Requests.
• Annual testing and validation of major benefit changes.
• Testing of existing or modifications of existing system setup. Testing for new developments and processes. Implements and tests system enhancements within the GE FRM Application. This includes any custom functionalities. Test and validate various software routines and algorithms, rule banks and night job rules within the GE FRM Application.
• Establish competency standards and comprehensive test plans or project plans.
• Reviews dictionary entries related to setup to ensure accuracy.
• Conduct testing of EDI processing system to ensure accuracy.
• Assists in the set up of specifications for electronic receipts/claim processing into the GE Applications. Develop and test new screen changes in the GE FRM Application (eg. edi, claims, referrals).
• Participates in the GE monthly financial close period.
• Works with third parties to test and implement electronic claims/receipt submission. Works with vendors on any new processes and communicates any modifications or issues (compliance update needs).
• Compares and tests fee schedules related to vendor contracts and vendor categories for accuracy and setup. Test coding rules with BRS interface
• Validates the integrity of database processing for EDI vendors and any other new enhancements.
• Monitors GE effectiveness and/or performance, identifies potential problems and proactively resolves issues.
• Challenges current processes and looks to introduce new methods and ideas.
• Coordinates execution of tests with multiple IS staff, Claims staff, and clients. Tracks and coordinates resolution of problems with staff and vendors.
• Provides analytical, technical and problem resolution standards.
• Assists in the development, implementation, testing to prepare for new productlines towards automation.
• Develop, implements and adheres to policies, procedures and standards.
• Assists in coordinating the development and implementation of procedures and standards.
• Assures adherence to AHC policies and procedures for system implementation and support.
• Maintains organized working documentation.
• Develops and prepares documentation and assures all project documentation is complete.
• Assists in recommending standards and configurations related to new products/enhancements by preparing written evaluations and assessments.
• Maintains a working knowledge of customer needs and business system policies and procedures regarding the use of the GE application.
• Analyze changes in procedures, policy and processing system to determine the need for new or revised training material.
• Provide leadership in the continued planning and process improvement initiatives of the Service Enhancement department in order to meet industry, professional and organizational standards.
• Maintain knowledge of current and future trends in training and managed care
• Maintain thorough knowledge of AHPO business operations
• Assists in the ongoing training of EDI process and or other new process/products not limited to the use of new functions, application of upgraded versions of the GE applications and major projects.

Other duties as assigned, including but not limited to.
Participate in/on process improvement and new enhancement committees.
Assists in the development of inter department process changes and communication.

Education/Experience Required:
Bachelor's degree or equivalent • 7-8 years experience in GE Claims Adjudication application, Managed Care claims, claims coding, managed care payor specific claims guidelines, and claims auditing • knowledge of various reimbursement methodologies. • Ability to work multiple projects simultaneously. • Advanced knowledge of Medicare and Medicaid regulations and guidelines and reimbursement.

Knowledge, Skills & Abilities Required:
• High level of proficiency in GE applications that impact business models. • Create clear concise detailed test plans/cases. Ability to understand test plan from specifications or verbal communication. • An attitude to ‘test to break’, detailed orientated, willingness to learn and suggest process improvements. • Liaison with development, project management and third party vendors. • Exceptional skills in interpreting contract language and reimbursement terms. • Efficiently manage workload, have high productivity, exhibit optimal time management and organization skills.

Physical Requirements and Working Conditions:
• Ability to manage multiple tests. • Flexible work schedule based on business needs. • Ability to work under pressure, within deadlines and in stressful conditions. • Willingness to. continue professional and technical development. • Previous lead or supervisory experience a plus.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.