Job Description

Job Description

We are seeking a Benefit Analyst with strong technical expertise to join our Business Operations team . This role focuses on translating complex Evidence of Coverage (EOC) documents into precise Epic Tapestry benefit configurations , ensuring accurate member cost shares, accumulators, and benefit limits. The analyst will collaborate closely with IT Application Analysts to implement new benefits, configuration changes, and system corrections with a high degree of accuracy and compliance.

Key Technical Responsibilities

• Interpret and analyze EOCs across multiple health plans and convert requirements into Epic Tapestry configuration .
• Configure and map benefit plans for diverse products (HMO, POS, Medi-Cal, Medicare, Exchange).
• Align CPT, HCPCS, REV, ICD-10 codes to benefit categories and validate coding logic.
• Analyze authorization rules and Division of Financial Responsibility (DOFR) for accurate system setup.
• Perform QA and validation of benefit configurations, including accumulators and cost-share logic.
• Execute system testing for new benefits and complex configuration changes within claims processing workflows.
• Investigate and resolve pending claims caused by configuration issues; adjudicate claims and apply corrective adjustments.
• Collaborate with IT to troubleshoot configuration errors, submit fixes, and document outcomes.
• Maintain benefit configuration standards, policies, and procedures; recommend process improvements for scalability.
• Conduct workflow analysis and consult on process optimization for new functionality and system upgrades.
• Partner with IT, Enrollment, Claims, and Contracting teams to ensure benefit accuracy and regulatory compliance.

Technical Requirements

• 5+ years in benefit configuration and claims within Managed Care or delegated model.
• Hands-on experience with Epic Tapestry (preferred).
• Strong knowledge of medical coding (CPT, HCPCS, REV, ICD-10) and claims adjudication logic.
• Familiarity with CMS mandates, NCDs, LCDs , and regulatory requirements for multiple plan types.
• Proficiency in Excel (VLOOKUP, Pivot Tables) and Microsoft 365 ; experience with data validation and QA testing .
• Certified Medical Coder (preferred) or equivalent coding expertise.
• Strong analytical and documentation skills; ability to work independently in a fast-paced environment.

Preferred Skills

• Experience with benefit mapping , system integration , and claims workflow optimization .
• Knowledge of cost-share accumulators , out-of-pocket maximums, and benefit limit logic.
• Familiarity with testing frameworks and QA methodologies for healthcare systems

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