The purpose of this position is to initiate and coordinate benefit systems configuration activities to ensure consistent administration and application of benefits as intended by products sold. The person in this position is responsible for synchronicity and alignment of benefits between Common Membership andEpic/Tapestry in addition to other benefits systems/applications; provides leadership in researching, identifying and resolving benefits discrepancies. The person in this position must understand and be able to communicate the business and systems impact of proposed changes/additions to products, plans or benefits. This position is supported by, and requires close collaboration with other department team members, including QA Analyst, EOC & ID card Vendor Lead, Regulatory Analyst and the Health Connect Benefit Application Coordinator(s).
Essential Functions
- Responsible for all aspects of contracts and benefits functions w/in Common Membership and Epic/Tapestry, including benefits design and analysis
- Responsible for synchronicity, alignment and integrity of benefits data between Common Membership and Epic/Tapestry systems, including Health Connect, and pharmacy, etc
- Develops and routinely provides benefits systems synchronization reports
- Develops and maintains documents, such as decision matrices, templates, benefits assumptions, desk top forms and other tools, that are used to validate benefits decisions and communicate those decisions to the benefits systems analysts and to others outside the department
- Collaborates with KPIT and project teams to manage and test benefits interfaces and data transfers between benefits systems and to other applications; participates in deployment of changes
- Coordinates and communicates necessary changes to benefits configuration due to policy decisions, product or plan changes, new plans or products; understands business impact due to the changes
- Provides leadership to dept staff and partner functional areas in research, identification, resolution and response to problems with benefits administration in one or more benefits systems. This includes having to articulate the benefit issue and formulate response/resolution when there is no precedent.
- Understands contractual requirements which influence benefit design options.
- Provides consultation on specific benefit interpretation and benefit administration issues; assists in training department personnel and others to understand benefits and optimize their use of benefits systems
- Maintains thorough knowledge of technology and resources available to dept analysts, working with dept management to ensure all staff are properly equipped and educated in their use
- Collaborates with product development to assess implications of new products or product design on benefit systems and benefit administration processes; identifies optimal ways to implement in benefits systems. Evaluates new or proposed systems or procedures and recommends improvements
- Demonstrates subject matter expertise in benefits configuration for each of the benefits administration systems
- Organizes knowledge sharing opportunities and activities among the department benefits systems analysts
- Responds to benefit inquiries from internal and external customers
- Serves as back-up for department Health Connect Benefits AC(s)
- Represents department on cross-functional workgroups, such as Ops Team
Qualifications:
Basic Qualifications
- Bachelor's degree or least 5 years experience in the healthcare industry, with strong experience in benefits or claims systems configuration.
- 5 + years of relevant health care industry experience including knowledge of health care operations and benefit administration.
- General knowledge of insurance claims processing systems; thorough knowledge of the techniques, procedures and claims processing methods.
- Demonstrated analytical capabilities.
- Experience in claims adjudication environment.
- Must have working knowledge of medical terminology and claims coding, including ICD, CPT, HCPCS, revenue codes.
- Thorough knowledge of managed care products and features and health insurance principles.
- Working knowledge of MS Office applications
- Demonstrated ability to manage multiple priorities working in a fast paced environment under intense deadlines.
- Strong communication and interpersonal skills.
- Strong analytical and problem solving, organization and planning skills.
- Familiarity with use and interpretation of quantitative reports and analysis.
Preferred Qualifications
- Bachelor's degree in Business Administration, Health Care Administration or related field preferred.
- Project Management experience preferred.
- 5+ years experience working with one of the region's benefit systems/applications, such as Common Membership (IRCS); Resolute/Tapestry (Epic). Health Connect (Epic) Benefits Engine Certification and/or Tapestry certification a plus.
- 5+ years of medical terminology or coding experience.
- 2+ years training experience in relevant field.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.