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Gold Coast Health Plan
Free to start · No card · 5 credits the moment you sign up
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.
Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their very best.
If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
**This role is open to California residents only.**
o Translate business requirements into accurate HRP configuration across benefits, provider contracts, pricing rules, accumulators, claims edits, and product variations.
o Build and maintain benefit structures, benefit dictionaries, coverage tiers, copays, deductibles, and EOC/Evidence of Coverage mappings.
o Configure provider reimbursement logic including fee schedules, capitation, FFS, value‑based rules, and DOFR constructs.
o Apply HRP tools (HealthRules Language™, Designer/Manager) to model complex logic without custom code.
o Develop detailed test scenarios and execute UAT for configuration changes, ensuring financial and non‑financial accuracy.
o Perform impact analysis for new configuration, regulatory updates, and system enhancements.
o Support production validation, post‑release monitoring, and defect remediation with clear traceability to requirements.
o Investigate adjudication issues, benefit discrepancies, and pricing errors using structured analysis.
o Identify root causes across configuration, requirements, provider contracts, and system logic.
o Document findings and collaborate with cross‑functional teams to implement corrective actions.
o Ensure configuration adheres to California regulatory requirements, including Medi‑Cal benefit structures, payment rules, and policy updates.
o Maintain awareness of state and federal regulatory changes and assess configuration impacts.
o Partner with Operations, Network, Product, Compliance, and QA to ensure configuration aligns with business goals and regulatory needs.
o Participate in requirements sessions, benefit design reviews, contract updates, and system enhancement planning.
o Provide subject‑matter expertise during audits, regulatory reviews, and cross‑departmental initiatives.
o Maintain clear documentation of configuration decisions, logic, test cases, and validation results.
o Support configuration governance processes, including standards, naming conventions, and version control.
o Contribute to playbooks, SOPs, and best practices for configuration quality and release readiness.
o Identify opportunities to streamline configuration processes and reduce defects.
o Support HRP upgrades, parallel testing, cutover readiness, and post‑go‑live stabilization activities.
o Mentor junior analysts and contribute to team knowledge development. Any other duties assigned
Education & Experience:
Technology & Software Skills: Advanced computer skills in MS Office products.
Certifications & Licenses: None
The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.
700Originally posted on Himalayas
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