Benefits Analyst - 25-180

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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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Hill Physicians has much to offer prospective employees.  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:

The Benefits Analyst is responsible for the review and validation of benefit coverage and applicable cost shares and MOOPs from benefit plan documentation and within system configuration. This person will ensure that data is correct, review the potential impact on the business, and work hand-in-hand with the IT Application Analysts to ensure that proper information and implementation of new
or changed benefits and necessary corrections are implemented timely.
 

Responsibilities and Tasks:

• Conducts detailed analysis of benefit plan documentation and validates coverage and cost shares configured in the claims processing system; including benefit limits and accumulators as necessary as applicable to new or existing benefit configuration.
• Evaluates and identifies potential errors in configuration and notifies IT Application Analysts, working to troubleshoot and make corrections in a timely manner, submitting and tracking necessary corrections to completion, documenting outcomes, and making recommendations as necessary.
• Assists with testing of new benefits and complex benefit configuration changes within the claims processing system as part of analysis and validation.
• Supports compliance as related to changes in applicable laws and regulations and reports any concerns or identified issues to supervisor and Compliance Team as necessary.
• Assists with implementation of written Policies and Procedures as well as continuous improvement strategies to drive efficiencies and ensure process viability in the future and across systems.
• Performs workflow analysis and consults on workflow/process improvement changes needed related to new functionality, applications, or systems.
• Performs review and analysis of pended claims resulting from benefit configuration issues and assists with resolution;
• adjudicates/finalizes pended claims while resolution of issue is in progress and assists with necessary adjustments of claims Assists with claims system implementation testing and quality assurance in advance of 2024 go-live; completes ‘super-user’ training as assigned by manager and/or training team leads.
• Communicates and asks necessary questions in a timely manner to assure data configuration accuracy.

Requirements:

• Understanding of how benefits configuration relates to claims adjudication and payment processes.
• Understanding of member responsibility/cost shares/accumulators and out-of-pocket maximums.
• Experience with testing/reviewing/validating benefit plans in QNXT and Epic/Tapestry; other claims platforms will be considered.
• Within scope of job, requires critical thinking skills, decisive judgement, and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.
• Exceptional analytical skills; proficient in data analysis - able to identify necessary data corrections and adjustments needed in large benefit and claims data sets.
• Ability to build and maintain interpersonal relationships with management, core Benefits staff, and interdepartmental colleagues.
• Ability to exercise independent judgment in planning, organizing, and performing systems analyst tasks.
• Strong excel and Microsoft office 360 skills.

Knowledge/Skills/Abilities:

• 3-5 years’ experience in the Managed Care, delegated model setting, in claims, benefits or revenue cycle.
• College degree in healthcare (preferred) or equivalent experience/knowledge