Benefit Analyst - Epic Tapestry ConfigurationHill Physicians Medical Group • San Ramon, CA, US
Benefit Analyst - Epic Tapestry Configuration
Hill Physicians Medical Group • San Ramon, CA, US
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job_description.job_card.job_description5+ 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. 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
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
Preferred Skills
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Configuration Analyst • San Ramon, CA, US