Benefits Plan Configurator I

Rady Children's Health Orange County (CHOC); Irvine (CA); Presencial; USD 65.000 - 90.000; Tempo integral

Resumo da vaga

Rady Children’s Health Orange County (CHOC) is seeking a Benefit Plan Building & Configuration professional to assist in building, testing, auditing, and maintaining medical, dental, pharmacy, vision, and ancillary benefit plans for employer groups. The role translates SPD provisions into claims system configuration under supervision.

This role develops proficiency in benefit interpretation, system configuration, QA testing, and claim adjudication processes.

Responsabilidades

• 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.
• Perform testing of benefit configurations and plan changes using 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.
• 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.
• 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.
• 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.

Descrição da vaga

Rady Children’s Health Orange County (CHOC) is seeking a Benefit Plan Building & Configuration professional to assist in building, testing, auditing, and maintaining medical, dental, pharmacy, vision, and ancillary benefit plans for employer groups. The role translates SPD provisions into claims system configuration under supervision.

This role develops proficiency in benefit interpretation, system configuration, QA testing, and claim adjudication processes.