Benefits Analyst

Job Description

Job Description

Job Summary

The Benefit Analyst is responsible for analyzing and managing the use of general funds for behavioral health care supports and services. The scope of this position includes tracking Medicaid spend down, maintenance of wait list and clinical care using general funds.

Essential Functions

Under direction :

• Leverages clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness for Reviews and Approvals using General Funds.
• Participate in workgroups and committees with other OCHN teams such as involvement in Access, Utilization Management and Quality Management, and with workgroups involving external providers.
• Accountable for timely and comprehensive review of clinical data and general fund benefit eligibility with concise documentation, decisions, and rationale.
• Conducts general fund benefit reviews for service authorizations as identified by OCHN.
• Conducts concurrent general fund clinical case reviews.
• Conducts retrospective general fund reviews of service provision to ensure services are provided in the appropriate amount, scope, and duration to reasonably achieve goals as outlined in the Individualized Plan of Service.
• Utilizes knowledge of protocols and audit tools to conduct general fund clinical audits to ensure inter-rater reliability within timeframes outlined.
• Works with OCHN billing specialist in the Finance Department to process and track Medicaid Spend Down.
• Develops and maintains the wait list as needed.
• Review and contribute to the development and continuous updating of protocols, audit tools, procedures, and processes within the Benefit Department.
• Additional duties as assigned.

Job Requirements and Qualifications

Education :

Training Requirements (licenses, programs, or certificates) :

Experience Requirements :

Knowledge Requirements :

Job Specific Competencies / Skills :

Oakland Community Health Network’s Core Competencies :

Additional Information

(Travel required, physical requirements, etc.) :

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees’ differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.