Program Manager Benefit Interpretation
Health Partners Plans
- Erie, PA
- Permanent
- Full-time
- Competitive Compensation Packages including 401(k) Savings Plan with Company Match and Profit Sharing
- Flextime and Work-at-Home Options
- Benefits & Wellness Program including generous Time Off
- Impact on the communities we service
- Primary subject matter expert in the interpretation of new and existing member benefits for all lines of business
- Works with Jefferson Health Plans compliance area to ensure products are being implemented according to existing and new regulations by line of business and industry standards.
- Analyzes explanation of coverage documents to lead multi-disciplinary group in determining best approach for loading benefits offered including member cost share and out-of-pocket maximums
- Leads definition of code sets used in benefits configuration and provider reimbursement
- Interprets minimum regulatory requirements for prior authorizations to be used in benefits configuration
- Collects and analyzes data to assess and resolve operational obstacles to benefits design optimization
- Serves as JHP’s expert on benefit related legislation
- Maintains documentation necessary for systems analysts to configure benefits
- Develops explanatory information for other departments to better understand benefits configuration across products
- Is a critical participant in the creation test scripts, including regression testing cases, to validate system configuration against source documentation.
- Cultivates collaborative and effective cross-functional relationships with key stakeholders including sales, marketing, operations, compliance, health care management and finance to ensure effective development and deployment of products across the organization
- Leads the Benefit Administration Committee
- Leads interdepartmental teams organized to ensure the effective management of Diagnoses and Service Codes implementation efforts, including clinical classing, age/gender edits and modifier assignments.
- Maintains documentation necessary for systems analysts to maintain code sets within systems
- Responsible for identifying and obtaining diagnosis and service codes on a quarterly basis
- Holds oversight responsibility for the Clinical Editing software
- Bachelor’s Degree required and 5 years’ experience in insurance industry in areas of Benefits Administration, Health Care Management or related field. RN and/or certified coder preferred.
- Must have demonstrated experience working with benefit design, preferred Medicare and Medicaid
- Ability to mine data and content, develop presentation and communicate concepts
- Experience with process improvement concepts and applications
- Excellent communication skills, including the ability to interface with all levels of management
- Detailed oriented with significant knowledge of heath care and public policy
- Demonstrated ability to lead and effectively work with multidisciplinary teams
- Strong problem solving skills
- PC Skills ( Word, excel, power point)