Hill Physicians Medical Group
Medical Claims Benefits Analyst
Hill Physicians Medical Group, San Ramon, California, United States, 94583
Overview
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. Base pay
$75,000.00/yr - $97,000.00/yr Note: Pay range provided by Hill Physicians Medical Group. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. 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 issues 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 365 skills Seniority level
Mid-Senior level Employment type
Full-time
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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. Base pay
$75,000.00/yr - $97,000.00/yr Note: Pay range provided by Hill Physicians Medical Group. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. 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 issues 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 365 skills Seniority level
Mid-Senior level Employment type
Full-time
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