Medical Claims Benefits Analyst - 25-186

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

We are seeking a Benefit Analyst to join our Business Operations team. This role is responsible for interpreting Evidence of Coverage (EOC) documents and translating them into accurate benefit configuration within the Epic Tapestry system, which includes member cost shares, maximum out of pockets and benefit limits.  The Benefit Analyst will work hand in hand with IT Application Analysts to ensure new or changed benefits, and necessary corrections are implemented timely and accurately.  The ideal candidate will have strong critical thinking and analytical skills, experience with benefit interpretation, medical coding and claims adjudication.

Key Responsibilities

• Benefit interpretation and analysis of EOCs across multiple health plans

• Mapping and/or configuration of new benefit plans and plan elements to support various health plan designs including HMO, POS, Medi-Cal, Medicare, and Exchange plans

• Analysis and alignment of CPT, HCPCS, REV, ICD-10 codes to benefit categories

• Analysis of authorization rules and Division of Financial Responsibility (DOFR)

• Conduct detailed analysis/quality assurance of benefit plan documentation and validate coverage and cost shares configured in Epic Tapestry system, including benefit limits and accumulators

• Assist with testing new benefits and complex benefit configuration changes within the claims processing system as part of analysis and validation

• Perform review and analysis of pending claims resulting from benefit configuration issues and assist with resolution

• Identify potential errors in configuration and notify IT working to troubleshoot and make corrections in a timely manner, submitting and tracking necessary corrections to completion, documenting outcomes, and making recommendations as necessary

• Adjudicate/finalize pending claims while resolution of issue is in progress and assist with necessary adjustments of claims that were unintentionally denied because of benefit configuration issue(s)

• Assist with maintenance of benefit requirements and configuration decisions and policies and procedures

• Continuous improvement of strategies to drive efficiencies and ensure process viability in the future and across systems

• Perform workflow analysis and consult on workflow/process improvement changes related to new functionality, applications, or systems

• Collaborate with IT, Enrollment, Claims, and Contracting teams to ensure benefit accuracy and compliance

• Other duties as assigned

Requirements

• 5+ years of experience in benefits and claims in Managed Care, delegated model setting

• Experience with benefit analysis and/or quality assurance

• College degree in healthcare (preferred) or equivalent experience/knowledge

• Certified Medical Coder (preferred), or equivalent experience/knowledge of medical coding

• Proficiency in CPT, HCPCS, REV Coding & Billing, and ICD-10.

• Experience with Epic Tapestry (preferred)

• Understanding of various health plan types and regulations including HMO, POS, Medicare, Medi-Cal, CMS mandates, NCDs, and LCDs

• Strong analytical, communication, and documentation skills.

Knowledge/Skills/Abilities

• Knowledge of how benefit configuration relates to claims adjudication and payment processes.

• Knowledge of member responsibility, cost shares, accumulators and out-of-pocket maximums.

• Experience with testing, reviewing, and validating benefit plans

• Critical thinking skills, decisive judgement, and the ability to work with minimal supervision.

• Must be able to work in a fast-paced environment with frequently shifting priorities and take appropriate action.

• Ability to build and maintain interpersonal relationships with management, core Benefits staff, and interdepartmental colleagues.

• Strong excel and Microsoft office 360 skills.

Additional Information

No of positions available: 2

Salary: $75,000 - $97,000 Annual

Hill Physicians is an Equal Opportunity Employer