Benefit Plan Builder I

Western Growers Health; Irvine (CA); On-site; USD 75,000 - 110,000; Full time

Job summary

Western Growers Health is seeking a Benefits Configuration Analyst to assist with building, testing, auditing, and maintaining medical, dental, pharmacy, vision, and ancillary benefit plans for employer groups. You will translate SPD provisions into claims system configurations and ensure accuracy across configurations and plan administration.

This role develops proficiency in benefit interpretation, system configuration, QA testing, and claim adjudication under senior guidance, collaborating

Qualifications

• BS/BA degree in Business, Computer Science, HealthCare Administration, or related field preferred. Minimum two (2) years of experience in health plan coding, benefit configuration, claims auditing, plan testing, or related health plan administration.
• Ability to interpret SPDs, Plan Documents, amendments and benefit summaries with guidance.
• Strong analytical skills with ability to identify discrepancies and research solutions.

Responsibilities

• Builds and configures medical, dental, pharmacy, vision and ancillary benefits in the claims system.
• Review SPDs and Plan Documents to translate plan provisions into configurations.
• Perform testing of benefit configurations and verify against SPDs and amendments.
• Identify and document configuration discrepancies and assist with issue resolution.
• Maintain documentation of configurations and testing results.
• Collaborate with internal teams to ensure accurate benefit implementation.

Skills

Analytical skills

Attention to detail

Communication skills

Microsoft Excel

Education

BS/BA degree in Business, Computer Science, HealthCare Administration, or related field preferred (minimum 2 years in health plan coding, benefit configuration, claims auditing, plan testing)

Tools

Microsoft Word

Microsoft Office

Job description

R Y

Reports to the Manager, Benefit Distribution & Installation and are responsible for assisting with accurate building, testing, auditing, and maintenance of medical, dental, pharmacy, vision, and ancillary benefit plans for new and existing employer groups. This position supports the configuration of benefit plans by translating plan provisions from Summary Plan Description (SPD), Plan Documents, amendments and administrative guidelines into the claims administration system.

J OB D ES C R I PT IO N S UM MA R Y

Reports to the Manager, Benefit Distribution & Installation and are responsible for assisting with accurate building, testing, auditing, and maintenance of medical, dental, pharmacy, vision, and ancillary benefit plans for new and existing employer groups. This position supports the configuration of benefit plans by translating plan provisions from Summary Plan Description (SPD), Plan Documents, amendments and administrative guidelines into the claims administration system.

This role develops proficiency in benefit interpretation, system configuration, quality assurance testing, and claim adjudication processes. This position performs assigned plan builds, testing activities, and issue resolution with guidance from senior team members while collaborating with internal departments to ensure accurate benefit implementation and ongoing plan administration.

Benefit Plan Building & Configuration

• Builds new business and benefit plan changes within the claims administration system under established departmental guidelines.
• Review Summary Plan Descriptions (SPDs), Plan Documents, amendments, and benefit summaries to accurately translate plan provisions into system configuration.
• Configure medical, dental, pharmacy, vision, and ancillary benefits as assigned.
• Ensure benefit configurations align with approved plan documents and administrative requirements.
• Assist with researching and responding to work orders received from Claims Examiners and internal stakeholders regarding plan issues, benefit discrepancies, and claim adjudication irregularities.
• Escalate complex configuration issues or discrepancies to senior team members for resolution.
• Maintain accurate documentation of benefit configurations, changes and completed work.

Benefit Plan Auditing & Quality Assurance

• Perform testing of benefit configurations and plan changes used established testing procedures.
• Complete peer audits of benefit builds performed by other team members to validate accuracy.
• Validate claim adjudication results against applicable SPDs, Plan Documents, amendments, and administrative guidelines.
• Identify and document configuration discrepancies, system issues, and potential claim impacts.
• Assist with researching and resolving audit findings under the direction of senior team members.
• Maintain testing documentation, audit results, and resolution tracking.

Process Improvement & Departmental Support

• Follow established procedures, workflows, and quality standards for benefit configuration and testing activities.
• Maintain tracking logs for assigned builds, audits, testing activities, and work orders.
• Assist with updating Standard Operating Procedures (SOPs), job aids, and training documentation.
• Identify opportunities for process improvements and communicate recommendations to leadership.

Professional Development & Team Collaboration

• Participate in departmental training, cross-training, and knowledge-sharing initiatives.
• Develop proficiency in benefit interpretation, claims adjudication, system configuration, and testing methodologies.
• Seek guidance from senior team members on complex benefit designs and configuration challenges.
• Support team initiatives and contribute to a collaborative work environment.
• Maintain current knowledge of departmental processes, system functionality, and health benefit administration policies.

Other

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• All other duties as assigned.

Qualifications

Q UA L IF IC A T IO NS

• BS/BA degree in Business, Computer Science, HealthCare Administration, or related field preferred. Minimum two (2) years of experience in health plan coding, benefit configuration, claims auditing, plan testing, or related health plan administration.
• Basic understanding of self-funded health plans, including medical, dental, pharmacy vision and ancillary benefits.
• Ability to interpret Summary Plan Descriptions (SPDs), Plan Documents, amendments and benefit summaries with guidance.
• Strong analytical skills with ability to identify discrepancies and research solutions.
• Strong attention to detail and commitment to accuracy.
• Ability to organize and prioritize multiple tasks while meeting established deadlines.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Office applications, specifically Word and Excel.
• Ability and willingness to learn claims administration systems and benefit configuration processes.
• Demonstrated ability to work collaboratively with internal teams and elevate issues appropriately.
• Ability and willingness to research and resolve routine technical issues and benefit configuration questions with appropriate guidance.