New York, New York
Metroplus Health Plan
About NYC Health + Hospitals
MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Develop and manage clinical benefit configuration process to ensure timely and accurate claims payment system configuration and claim processing. Responsible for the codification and mapping of benefit product building, including the development and maintenance of the benefit configuration document and attaching appropriate service rules required for each benefit category. Serve as subject matter expert in all areas of the medical plan configuration, medical utilization edits, service payment limits and service rules. Develop workflows and business processes to ensure timely and accurate system build. Act as a facilitator to accurately translate product benefit and all aspects of the service rules into a configurable document. Provide business requirements to CORE configuration for purposes of translating clinical concepts into system configuration requirements. Provide guidance to employees and providers regarding documentation concerns as they relate to coding and billing.
Associated topics: biopharma, cytometry, drug development, drug discovery, industrial hygienist, medical, nutrition, pharmacy, toxicologist, trauma