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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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

Knowledge / Skills / Abilities

Additional Information

No of positions available : 2

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

Hill Physicians is an Equal Opportunity Employer