Benefit Plan Builder

Job description:
The purpose of this position is to build and maintain our clients' plan of benefits using the RIMS processing system for the most automated and correct adjudication of claims. The plan builders will be "super users" of the RIMS system and serve as a resource to management and IT in getting the most performance out of RIMS. Plan builders will serve as a trouble-shooter for researching and solving processing problems as they relate to the company's claims processing software and our own internal procedures. Plan builders will serve as testers for each new software release to ensure system is working as designed. If assigned, the plan builders will work special projects from management concerning the adjudication of claims and client-specific processing required to meet a group's particular needs.

Responsabilities:

• Plan Setup & Administration: Build new group and product plans in RIMS, including run-in plans, using internal tools and checklists to ensure accurate configuration and claims adjudication.
• Plan Design Review: Analyze plan documents, amendments, policies, and mandates. Provide feedback and recommendations to improve system-based adjudication.
• Documentation & Reporting: Maintain up-to-date records of all active plan build tasks. Document processing notes, exception codes, and upload finalized data to client files.
• Renewals, Amendments, and Rewrites: Manage benefit changes, freeze/release updates in RIMS, and test for accuracy before finalizing based on approvals.
• Compliance Monitoring: Implement benefit changes as required by group policies, certificates, or state compliance updates.
• Claim Support: Respond to claims inquiries, troubleshoot system issues, make necessary changes in RIMS, and assist with mailbox management for timely resolution.
• Plan Testing & Auditing: Perform system testing and peer audits on new builds or changes to ensure alignment with plan design.
• Collaboration & Communication: Participate in meetings, communicate plan updates to key departments (ID cards, billing, consultants), and ensure coordination with other plan builders.
• Training & Support: Train internal teams (claims specialists, CAs, etc.) on new or updated plans using documented notes and codes.
• System Optimization: Work with IT to improve RIMS functionality, test updates, and share new system capabilities with team members.
• Special Projects & Provider Arrangements: Collaborate on unique provider contracts and automate processing in RIMS. Document and train others as needed.
• Other Duties: Assist with reporting, special assignments, and additional tasks as delegated by management.

Skills and qualifications - Hard and soft skills:
· Experience using either QicLink or VBA platforms . Four to six years of high level claims processing and benefit knowledge · Medical terminology and coding · Two-three years of RIMS system experience · One to two years of plan building experience · Reinsurance and specific and aggregate contract knowledge · General insurance knowledge and familiarity with federal laws affecting self-funding · Problem–solving skills · Ability to multi-task · Must be able to organize own work to control processes and meet deadlines · Excellent written and verbal communication skills especially in technical and report writing · Mathematical proficiency · Ability to work with other team members to control work load as well a work independently · Must follow-up on tasks until completed · Be reliable, timely, punctual, flexible, and emotionally mature · Take initiative, show leadership and ability to work under pressure · Display good corporate citizenship · Work professionally and respectfully with other departments