Coding and Benefits Analyst

Title:

Benefit & Coding Analyst III

Our Client is seeking a Benefit & Coding Analyst III to analyze, develop, and maintain benefit and coding requirements at the enterprise level across multiple markets and lines of business. This role requires deep expertise in medical coding, benefit configuration, and regulatory compliance to ensure system accuracy and alignment with benefit definitions. The analyst will collaborate with cross‑functional teams to interpret requirements, troubleshoot issues, and provide subject matter expertise supporting configuration, product strategy, operational processes, and system accuracy.

The Benefit & Coding Analyst III will also play a key role in supporting annual benefit changes, quarterly coding updates, and ensuring compliance with federal, state, and CMS regulations. The ideal candidate will have at least five years of experience in medical coding and benefit configuration, strong analytical and communication skills, and a thorough understanding of Medicare, Medicaid, and Marketplace benefit structures.

• Analyze and translate complex medical benefit requirements into system configurations and coding specifications across multiple states and product lines.
• Develop, maintain, and validate code‑level benefit definitions using correct coding methodologies, coding guidelines, and regulatory requirements.
• Create and review configuration templates and benefit grids to ensure alignment between benefit intent, coding logic, and system design.
• Research and interpret federal, state, and CMS regulations, including prior authorizations, EHB requirements, OPPS rules, MHPAEA compliance, and provider contract alignment.
• Participate in and support annual benefit change and quarterly coding update processes, ensuring timely implementation and compliance.
• Utilize reporting tools to analyze data, conduct impact assessments, resolve issues, and perform root cause analysis.
• Support cross‑functional teams through effective communication, documentation, process improvement, and troubleshooting.
• Provide mentorship, peer reviews, and training to colleagues to ensure consistency and quality of work.
• Create and maintain SOPs, process flows, and operational documentation.
• Serve as backup or lead on assigned projects, internal/external meetings, and operational priorities as needed.

• Bachelor’s degree in a related field or equivalent experience required.
• Minimum five (5) years of experience in medical coding, benefit plan design, benefit configuration, or claims processing.
• Subject matter expertise in CPT, HCPCS, and ICD‑CM coding.
• Experience with benefit configuration systems (Facets or equivalent preferred).
• Strong analytical, problem‑solving, and critical thinking skills.
• Understanding of claims-related reference data (revenue codes, bill types, POS, etc.).
• Knowledge of Medicare, Medicaid, and Marketplace benefit structures highly preferred.
• Managed Care experience strongly preferred.
• Proficient with Microsoft Office Suite; database knowledge preferred.
• Strong written and verbal communication skills.
• Ability to work independently or collaboratively in a fast‑paced environment.