Location: Durham, NC
Duration: 18+ Months
- The Benefits Design Analyst is responsible for assisting in the evaluation, design, testing, and implementation of required health plan benefits and payment structure changes.
- The incumbent of this position must possess strong analytical skills, with the ability to perform complex business and product set up requirement analysis in a fast-pace environment.
- The Benefits Design Analyst serves as a subject matter expert (SME) on both corporate projects and departmental business initiatives that require PowerMHS benefits configuration modifications.
Duties & Responsibilities:
- Assist in the on-going evaluation of benefits configuration for new and existing benefit plans within PowerMHS.
- Analyze explanation of coverage documents to assist with determining best approach for loading benefits offered including member cost share and out-of-pocket maximums.
- Assist in the setup of code sets and defining pre-authorization guidelines used in benefits configuration and provider reimbursement.
- Liaison with applicable departments to gather benefits configuration requirements and provide feedback to stakeholders regarding feasibility of change implementation.
- Collect and analyze data to assess and resolve operational obstacles to benefits design optimization.
- Perform root-cause analysis on benefit set up issues across all products, document results and present business impact analysis for proposed benefits set up changes.
- Develop explanatory information for other departments to better understand benefits configuration across products.
- Identify ways to enhance performance management and operational reports related to new business implementation processes.
- Monitor existing system functionality and make benefits set up recommendations, where appropriate, to maintain acceptable levels of automation in claims adjudication and accurate provider reimbursement.
- Aid in the creation test scripts, including regression testing cases, to validate system configuration against source documentation.
- Assist with organizing the release of benefits configuration changes to production to reduce the potential for migration conflict.
- Ensure the quality and integrity of implementation of benefits change requests through the use of production validation and audit strategies.
- Provide project and informational updates to management as available and/or assigned.
- Collaborate with business units to understand strategic goals and promote an environment conducive to creativity, change and information exchange.
- Additional duties as assigned
- Associate’s degree from an accredited institution.
- Previous managed care/health plan experience in an operations department where you have you have been responsible for implementing new products or benefits into plan systems.
- Experience delivering benefit implementation processes within a Claims Operations or Product Management environment.
- Experience gathering and communicating complex benefit configuration requirements in a simple and easy to understand manner to other staff.
- As the SME, the Benefits Design Analyst will need to effectively communicate with all levels of the organization, including technical staff, internal non-technical staff, testing teams, and business stakeholders.
- Experience gathering and converting data into written narratives that will be used for updating benefit implementation project stakeholders and to make recommendations on benefit configuration system changes needed.
- Hands-on experience with rules based table driven claims and eligibility administration systems (i.e. PowerMHS or any other claims processing systems).
- Proficiency in medical terminology, medical coding (CPT4, ICD9 or ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
- Experience using project tracking, testing and requirement tools (i.e. MS Project, SharePoint or any other time management system).
- Experience with MS Excel functions that include creating standardized reports, utilizing vLookups, pivot tables, filtering and formulas to generate desired results.