What you will do
Design, configure, implement, test, and maintain health plan claims administration systems, including benefits, fee schedules, provider reimbursement methodologies, claims editing rules, authorization requirements, and related workflows to support accurate and automated claims adjudication.
Interpret and translate Evidence of Coverage (EOCs), Summary of Benefits and Coverage (SBCs), provider contracts, reimbursement methodologies, medical policies, coding updates, and regulatory requirements into compliant system configuration and technical specifications.
Configure and maintain claims editing software and coding logic, including ICD-10-CM, CPT, HCPCS, modifiers, NCCI edits, CARC/RARC codes, revenue codes, and reimbursement edits to ensure accurate claims pricing, payment, and compliance with coding standards and payer policies.
Perform end-to-end testing, validation, and quality assurance of system configuration changes to ensure claims adjudicate accurately according to benefit design, provider contracts, coding guidelines, and applicable federal and state regulations.
Investigate, troubleshoot, and resolve claims processing issues, payment discrepancies, suspended or denied claims, and configuration defects by conducting root cause analysis and implementing corrective system solutions.
Research, evaluate, and implement quarterly and ongoing updates to medical coding, reimbursement methodologies, regulatory requirements, and health plan policies to ensure system configurations remain current and compliant with CMS, Medicare, Medicaid, ACA, HIPAA, NCQA, and commercial payer requirements.
Develop and maintain configuration documentation, testing plans, workflow documentation, audit trails, and technical specifications to support configuration management, regulatory compliance, accreditation activities, and organizational change management.
Collaborate with Health Plan Operations, Clinical Services, Provider Network, Compliance, Finance, Information Technology, vendors, and other stakeholders to translate business requirements into effective system solutions and support enterprise health plan initiatives.
Serve as a subject matter expert for claims configuration, coding, reimbursement methodologies, and health plan system functionality by providing technical guidance, supporting production issues, participating in system implementations and upgrades, and promoting continuous operational improvement.
Essential Qualifications
The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.
Required Education, License/Certification, or Work Experience
Certified Coding Associate (CCA) - American Health Information Management Association (AHIMA) or other nationally recognized coding organization Upon Hire or
Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC) Upon Hire or
Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA) Upon Hire
Epic Certification - Epic Epic Tapestry Certification or required to participate in Epic coursework and pass certification exams within 90 days of hire. within 90 Days
4-6 years Coding with knowledge and understanding of provider reimbursement methodologies, medical terminology, human anatomy, physiology, ICD-10-CM, CPT, HCPCS coding, and NCCI edits.
Demonstrated critical thinking skills through evaluation, analysis, and creative solutions.
Ability to think broadly, identifying and understanding implications to the entire organization including excellent communication, documentation and problem-solving skills.
Ability to work independently and as part of a cross-functional team.
Preferred Education, License/Certification, or Work Experience
Bachelor's in Healthcare Administration, Information Systems, or related field or Epic Tapestry Certification with 3+ years of experience.
4-6 years Experience with complex system design, preferred experience with claims adjudication platforms or ecosystems, specifically Epic Tapestry.
Background and knowledge of Health Plans operations and understanding of health plan processes, systems and regulations including claims processing, benefit configuration, enrollment and provider networks. Including familiarity with CMS regulations, HIPAA and payer-provider contracting.
Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
Experience with Epic Chronicles and data models, Care Management or other related modules.
Familiarity with EDI (Electronic Data Interchange) formats (e.g., 834, 837, 835) and integration best practices.
Expectations and Standards
Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
Promote Avera’s values of compassion, hospitality, and stewardship.
Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
Maintain confidentiality.
Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.
Benefits You Need & Then Some
Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.
PTO available day 1 for eligible hires.
Up to 5% employer matching contribution for retirement
Career development guided by hands-on training and mentorship
Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to talent@avera.org.
