Benefits Plan Configuration Specialist

Summary of role:

As a Benefits Plan Configuration Specialist, you will focus on understanding, translating, and configuring medical and dental plan designs into the core claims platform to ensure accurate processing of claims. You will maximize effectiveness of the core claims platform by continuously evaluating current processes and business needs along with system capabilities. You will create logic sets, based on code mapping, with an emphasis on accuracy and proficiency.

Responsibilities Include:

• Create the blueprint for configuration of the plan from plan documents and/or plan standards.
• Build, validate and test medical and dental plan benefits and associated code mapping logic.
• Make necessary plan building and logic revisions when plans are amended.
• Build auto-adjudication logic and test for integration with plan.
• Resolve system issues and act as contact for opening and closing jobs on the core claims platform job list.
• Test open jobs on new releases from the core claims platform and troubleshoot problems prior to loading into production.
• Troubleshoot system problems, develop resolutions and/or “work around” procedures.
• Work with Department Managers, Team Leaders, and other applicable personnel to improve efficiency within the company.
• Coordinate the development of solutions for system-related issues that may prevent the use of automated or standard processing methods.
• Communicate changes to other departments and help with any required training necessary because of system changes.
• Maintain the claim system Plan Building mailbox to research and resolve system issues.

Qualifications:

Required Skills and Abilities:

• Knowledge of professional and institutional claims adjudication.
• Ability to interpret plan documents and amendments and translate benefits to ICD 10, HCPCS, CPT, CDT and other insurance billing codes.
• Exemplary customer service skills demonstrated by researching and resolving issues that are configuration-related in a timely and accurate manner.
• Ability to adapt to a constantly changing environment.
• Demonstrated organizational skills and ability to work independently, problem-solve, and make decisions.
• Demonstrated ability to work in a fast-paced, agile environment managing multiple issues with pressure of production schedules and deadlines.
• Demonstrated ability to work collaboratively and influence others to drive results across multiple functional teams.
• Proficiency in Microsoft Office applications and other web-based software applications.
• Ability to learn new proprietary computer systems.

Education and Experience:

• Prior experience with a highly automated and integrated claim adjudication system.
• Prior experience in a startup environment is a plus.

Preferred Qualifications:

• 4 to 5 years of health insurance-related Plan Building experience with TPA and Self-Funding processes.
• Associates or Bachelor’s degree preferred.