Benefits Analyst

Job Summary

The Benefit Analyst is responsible for the configuration, maintenance, and validation of member benefits to ensure accurate claims adjudication. This role translates benefit plan documents, regulatory requirements, and business rules into system configurations that support correct and timely claim payments.

The Benefit Analyst ensures annual benefit updates are accurately implemented across claims platforms so that member claims process in accordance with plan design, CMS requirements, and contractual obligations.

Key Responsibilities

Primary duties may include, but are not limited to:

• Configure annual and ongoing benefit updates in claims adjudication and benefits administration systems.
• Translate benefit plan documents, summaries of benefits, and regulatory requirements into system build specifications.
• Ensure benefit structures are accurately set up to support correct claims payment based on plan design.

Benefit Configuration & Maintenance

• Build and maintain benefit plans.
• Configure key benefit elements such as:

• Copayments, coinsurance, and deductibles
• Coverage limitations and exclusions
• Authorization requirements
• Service category definitions

• Ensure benefit configuration aligns with plan documents and regulatory requirements.

Annual Benefits Updates

• Implement annual benefit changes, including new plan year updates and mid-year regulatory adjustments.
• Validate benefit updates prior to production deployment to ensure accuracy of claims adjudication.
• Coordinate with internal stakeholders to ensure timely implementation of benefit changes within required regulatory and operational timelines.
• Support testing cycles for annual benefit changes, including unit testing and user acceptance testing (UAT).

Claims Adjudication Support

• Ensure configured benefits accurately drive claims payment outcomes.
• Research and resolve benefit-related claims issues and adjudication discrepancies.
• Support claims operations by interpreting benefit logic and system configuration impacts.
• Assist in identifying root causes of benefit-related claims payment errors.

Policy Interpretation & Analysis

• Interpret benefit plan documents, evidence of coverage (EOC), and summary of benefits (SOB).
• Translate business requirements and regulatory guidance into system configuration rules.
• Ensure compliance with CMS requirements, including Medicare Advantage benefit standards where applicable.
• Analyze benefit design changes and their downstream impact on claims processing and member experience.

System Testing & Quality Assurance

• Perform validation and testing of benefit configurations in claims systems.

• Identify and correct configuration errors prior to production release.
• Support regression testing for system upgrades, benefit changes, and configuration enhancements.
• Document test results and configuration changes for audit and compliance purposes.

Collaboration & Communication

• Partner with Product, Actuarial, Compliance, and Claims Operations teams to ensure accurate benefit implementation.
• Respond to internal inquiries regarding benefit structure and claims adjudication outcomes.
• Provide subject matter expertise on benefit design and system configuration logic.

Compliance & Regulatory Requirements

• Ensure benefit configurations comply with CMS regulations, plan documents, and internal policies.
• Maintain accurate documentation of benefit rules and configuration logic for audit readiness.
• Support regulatory audits and compliance reviews related to benefit design and claims processing.

Minimum Qualifications

• High School Diploma or GED required.
• Minimum of 3-5 years of experience in health insurance, managed care, claims configuration, or benefit administration.
• Experience working with benefit plan documents and claims adjudication systems.
• Strong understanding of healthcare benefits structure and claims processing concepts.

Preferred Qualifications

• Experience in Medicare Advantage, Medicaid, or commercial managed care environments.
• Familiarity with CMS benefit requirements and regulatory frameworks.
• Experience with benefit configuration tools or claims system administration.
• Knowledge of healthcare claims adjudication and reimbursement principles.

Skills & Competencies

• Strong analytical and problem-solving skills
• High attention to detail and configuration accuracy
• Ability to interpret complex benefit plan documents
• Strong understanding of claims systems and benefit logic
• Excellent organizational and documentation skills
• Ability to manage multiple annual and ad hoc benefit updates
• Strong collaboration and communication skills