Lead the configuration and optimization of Facets and Optum NetworX (Pricer and Modeler) systems to support accurate claims adjudication for a growing health plan. This position plays a central role in transforming regulatory requirements, provider contracts, and business policies into precise technical configurations that drive reliable reimbursement outcomes.
Key Responsibilities
- Direct the implementation and configuration of NetworX pricing agreements, using provider data to enhance operational performance.
- Act as a technical authority on Facets and NetworX systems, resolving complex configuration issues and identifying root causes.
- Interpret CMS guidelines, payer-provider contracts, and benefit designs to develop compliant and efficient system setups.
- Partner with IT, claims, provider services, and business teams to refine integrations and improve system functionality.
- Design, document, and maintain configuration standards, ensuring consistency and audit readiness.
- Validate system behavior to confirm correct claim processing and provider payments; identify opportunities for automation.
- Lead testing, system upgrades, and deployment activities with minimal operational impact.
- Provide training and technical guidance to internal teams, working within Agile/Scrum frameworks.
Required Qualifications
- Minimum of 10 years’ experience with Facets, NetworX Pricer, Optum Grouper/Pricer, and U.S. healthcare claims operations.
- At least 5 years managing large-scale configuration projects in hybrid delivery environments.
- Proven track record in end-to-end configuration for new lines of business.
- Strong grasp of managed care models, provider agreements, fee schedules, and benefit structures.
- Proficient in writing and tuning SQL queries for data validation and reporting.
- Experience configuring Facets Provider modules and Optum PPS systems.
- Ability to convert contractual terms into technical specifications and system configurations.
- In-depth knowledge of Medicare, Medicaid, Marketplace, LTSS, and DSNP programs.
- Hands-on experience with Facets v25.R1 or later on SQL platforms.
- Excellent communication skills and demonstrated problem-solving capabilities.
Preferred Skills
- Experience managing large-scale production cutover events and configuration rollouts.
- Familiarity with Cognos, Power Automate, and standard office productivity tools.
- Use of AI-assisted tools like Copilot or ChatGPT to improve documentation and analysis workflows.
- Adaptability in fast-moving environments, balancing independent work with team collaboration.
