Hill Physicians Medical Group
Medical Claims Benefits Analyst - 25-186
Hill Physicians Medical Group, San Ramon, California, United States, 94583
Medical Claims Benefits Analyst - 25-186
Join to apply for the
Medical Claims Benefits Analyst - 25-186
role at
Hill Physicians Medical Group .
We’re delighted you’re considering joining us! 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.
We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.
DE&I Statement: 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 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
Number of positions available: 2
Salary: $75,000 - $97,000 Annual
Hill Physicians is an Equal Opportunity Employer.
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Medical Claims Benefits Analyst - 25-186
role at
Hill Physicians Medical Group .
We’re delighted you’re considering joining us! 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.
We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.
DE&I Statement: 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 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
Number of positions available: 2
Salary: $75,000 - $97,000 Annual
Hill Physicians is an Equal Opportunity Employer.
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