Healthcare Configuration Analyst (Medi-Cal/HRP)

Gold Coast Health Plan; California; On-site; USD 100,000 - 150,000; Full time

Job summary

Gold Coast Health Plan is seeking an experienced HRP configuration analyst to translate business requirements into precise configuration across benefits, pricing rules, and provider contracts. You will model complex logic with HealthRules Language and use Designer/Manager to ensure accurate, auditable outcomes.

Ideal candidates have 2–5 years of HRP hands-on experience, California Medi-Cal familiarity, and strong testing, documentation, and collaboration skills.

Qualifications

• 2-5 years of hands-on HRP configuration across benefits, provider contracts, pricing rules, and claims edits.
• California health plan experience with Medi-Cal preferred.
• Strong understanding of payer operations, claims adjudication, reimbursement methodologies, and regulatory constructs.
• Proficiency with HealthRules Language, Designer/Manager (Answers/Connector a plus).
• Experience with healthcare EDI and code sets (HIPAA 837/835/834/270/271; ICD10, HCPCS, CPT, DRG, APC, NDC).
• Demonstrated ability to translate complex business requirements into accurate configuration with documented rationale.
• Strong skills in test planning, UAT execution, impact analysis, and production validation.
• Excellent communication, analytical, and documentation skills.
• Ability to work independently and collaboratively in a remote, fastpaced environment.

Responsibilities

• Translate business requirements into HRP configuration across benefits, provider contracts, pricing rules, accumulators, claims edits, and product variations.
• Build and maintain benefit structures, benefit dictionaries, coverage tiers, copays, deductibles, and EOC/Evidence of Coverage mappings.
• Configure provider reimbursement logic including fee schedules, capitation, FFS, valuebased rules, and DOFR constructs.
• Apply HRP tools (HealthRules Language, Designer/Manager) to model complex logic without custom code.
• Develop detailed test scenarios and execute UAT for configuration changes, ensuring financial and nonfinancial accuracy.
• Perform impact analysis for new configuration, regulatory updates, and system enhancements.
• Support production validation, postrelease monitoring, and defect remediation with clear traceability to requirements.
• Investigate adjudication issues, benefit discrepancies, and pricing errors using structured analysis.
• Identify root causes across configuration, requirements, provider contracts, and system logic.
• Document findings and collaborate with crossfunctional teams to implement corrective actions.
• Ensure configuration adheres to California regulatory requirements, including MediCal benefit structures, payment rules, and policy updates.
• CrossFunctional Collaboration with Operations, Network, Product, Compliance, QA; participate in audits and reviews.
• Maintain clear documentation of configuration decisions, logic, test cases, and validation results.
• Support configuration governance processes, including standards, naming conventions, and version control.
• Contribute to playbooks, SOPs, and best practices for configuration quality and release readiness.
• Continuous Improvement: identify opportunities to streamline processes, support HRP upgrades, and mentor junior analysts.

Skills

HRP configuration

HealthRules Language

Provider contracts

Regulatory compliance

Test planning

Documentation

Education

Bachelor's degree

Tools

Designer/Manager

Answers/Connector

Job description

Gold Coast Health Plan is seeking an experienced HRP configuration analyst to translate business requirements into precise configuration across benefits, pricing rules, and provider contracts. You will model complex logic with HealthRules Language and use Designer/Manager to ensure accurate, auditable outcomes.

Ideal candidates have 2–5 years of HRP hands-on experience, California Medi-Cal familiarity, and strong testing, documentation, and collaboration skills.