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Benefits Specialist


The IT department is seeking a Benefits Specialist to assist with benefit table setup including explanation and interpretation of benefits as specified in health plan contractual arrangements.

Duties and Responsibilities

  • Responsible for designated benefit set setup based on line of business and/or health plan code
  • Link appropriate benefit tables/sets to corresponding health plan benefit options
  • Understand ICDx and CPT/HCPS relationship in order to document coverage of services
  • Verify that the benefit table setup is correct and perform periodic testing to validate configurations
  • Research questionable coverage issues identified in the health plan benefit coverage documents
  • Answer benefit questions as they arise from internal and external staff
  • Coordinate setup with DOFRs team
  • Work closely with the claims team to ensure that co-payments and deductibles are set up correctly at the member, health plan and benefit option level
  • Track accumulators for Covered CA Exchange members and report to the health plan as requested
  • Additional IT Benefits tasks as directed


  • High school graduate or GED equivalent
  • Minimum of two years’ experience handling benefit setups in a IPA or health plan environment
  • Understanding of Managed Healthcare

Knowledge, Skills and Abilities Required:

  • Effective verbal and written communication skills
  • Good interpersonal skills
  • Ability to multitask in a busy department
  • Excellent organizational skills
  • Moderate knowledge of ICDx and CPT/HCPS coding
  • Knowledge regarding claims billing rules a plus
  • Able to stay focused on the telephone despite noise and other distractions
  • Microsoft Office skilled (proficiency in Excel a plus)
  • EZ-CAP® knowledge including Benefit Matrix (BM) setup a plus

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Job title: Benefits Specialist

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