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Company Description
Neltner Business Services Pvt Ltd, based in Chennai, has been delivering knowledge-based solutions to the healthcare and legal industries in the United States since 2010 a subsidiary of Netmarkservices . As a fast-growing organization, the company is known for its customer-centric approach and dedication to quality service. Neltner prioritizes fostering a strong work ethic and maintaining a motivated and engaged team. Their commitment to excellence has made them a trusted partner for clients in highly regulated industries.
Role Description
Key Responsibilities
1. Optum CES Configuration & Management
- Serve as the primary technical and operational SME for the Optum Claims Editing System (CES).
- Analyze, design, and configure custom and standard claims editing rules (e.g., unbundling, mutually exclusive codes, age/gender conflicts, duplicate logic) within Optum CES.
- Manage regular software and content updates from Optum, assessing the impact of new edits on existing Medi-Cal business rules and claims workflows.
2. HealthRules Payor (HRP) Integration
- Ensure seamless integration and data flow between Optum CES and HealthRules Payor (HRP).
- Map and reconcile EDI transactions (837/835) between CES and HRP to ensure accurate adjudication and payment integrity.
- Collaborate with the HRP configuration team to ensure that benefit plans, pricing models, and provider contracts configured in HealthRules do not conflict with CES editing logic.
3. Medi-Cal & Regulatory Compliance
- Ensure all CES configurations strictly adhere to California DHCS policies, Medi-Cal Provider Manuals, and Medicaid NCCI edit guidelines.
- Implement state-specific editing logic for Medi-Cal modifiers, aid codes, and Treatment Authorization Requests (TARs) / Service Authorization Requests (SARs).
- Partner with the Compliance and Provider Network teams to translate complex state and federal mandates into actionable system edits.
4. Cross-Functional Collaboration & Testing
- Collaborate with Claims Operations, Provider Relations, and Business Analysts to identify trends in claim denials and recommend proactive CES rule changes to improve first-pass resolution rates in HealthRules.
- Lead functional testing, User Acceptance Testing (UAT), and regression testing for all CES rule implementations, system upgrades, and HRP connector updates.
- Document system configurations, business requirements, and standard operating procedures (SOPs) for the claims editing lifecycle.
- Experience reqiured Minimum of 3–5 years of hands-on experience in healthcare IT or claims configuration, with direct experience configuring and managing Optum CES.
- Core System Knowledge: Direct experience working with HealthRules Payor (HRP) by HealthEdge, specifically understanding how it interacts with secondary claims editors.
- Medi-Cal Knowledge: Deep understanding of Medi-Cal/Medicaid claims processing, California DHCS billing guidelines, and PPS reimbursement structures.
- Coding Expertise: Strong working knowledge of medical terminology, CPT, HCPCS, ICD-10, Revenue Codes, and CMS NCCI edits.
- Technical Skills: Experience with healthcare EDI standards (specifically 837 and 835 transactions) and issue resolution between primary systems and secondary editors.
Optum CES & Core Logic questions for the candidates to answer :
1. Experience with CES? Version?
2. Scenario: Optum releases a new quarterly content update. Walk me through your process for reviewing, testing, and promoting this update into our production environment. How do you identify which new standard edits might negatively impact our current auto-adjudication rates?
3. Custom Edits: Can you describe a time when you had to build a custom rule/edit in Optum CES because the standard logic didn't meet a specific business need? What was the logic, and how did you test it?
4. What steps do you take when a pattern applied to a claim and you do not want the rule to apply to the claim? Can you explain the steps?
5. NCCI vs. State Rules: How do you handle situations in CES where a CMS NCCI edit conflicts directly with a state-specific Medi-Cal billing rule?
HealthRules Payor (HRP) Integration
4. System Synergy: HealthRules Payor handles benefit configuration and pricing, while Optum CES handles secondary editing. Can you explain how you troubleshoot an issue where a claim is denying for a bundled service in CES, but the provider relations team insists it should be paid based on the contract configured in HRP?
5. Data Flow: Describe the data flow of an 837 claim as it enters the clearinghouse, passes through HealthRules Payor, hits Optum CES, and returns. Where do you typically see integration breakdowns occur?
Medi-Cal Specifics
6. State Modifiers: Medi-Cal heavily relies on specific modifiers for reimbursement (e.g., EPSDT modifiers, family planning). How have you previously configured CES to ensure claims with these state-specific modifiers bypass standard unbundling or mutually exclusive edits?
7. TARs/SARs: How do you configure claims editing logic to accurately read and match Treatment Authorization Requests (TARs) on a claim before allowing the service lines to pay?
If you suit the criteria mentioned please share resumes to nsundaram@netmarksvs.com
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