Responsibilities
- Using close and comprehensive analyses, verify new and existing plans loaded on the Company’s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments
- Test all new plans prior to loading them into production (medical, dental and vision plans)
- Work with programmers to test claims and related system programs to verify impact within the HCPS
- System analysis and testing of mass system updates
- Plan coding of new business and plan changes for medical, dental, and vision plans
- Communicate with other operational departments, as necessary, to ensure smooth integration of new plans for both WGAT and PCMI moving into production
- Provide monthly reporting of all requested plan issues submitted from the Claims department
- Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses
- Create and document Standard Operating Procedures (SOP)
- Identify, initiate and implement process improvements and/or innovation
- Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members
- Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively
- Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results
Requirements
- BS/BA degree in Business or related field
- a minimum of three (3) to (5) five years of recent experience as a medical/dental claims auditor or plan testing experience
- Exceptional understanding and ability to interpret summary plan descriptions of employee medical/dental benefits
- Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demanding environment to meet expected goals, dates, and milestones
- Ability to anticipate problems, recommend solutions, and exercise best judgement
- Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials
- Proficient ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts
- Previous experience with conducting research and presenting complex information
- Excellent communication and interpersonal skills
- Superior organization skills and high attention to detail
- Ability to learn complex business processes and appropriately apply knowledge to make informed decisions
- Advanced skills in Microsoft Office applications
- Knowledge of medical terminology
- Familiar with ICD10, CPT, HCPC, and CDT codes
- Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds
- Home router with wired Ethernet (wireless connections and hotspots are not permitted)
- A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
- A functioning smoke detector, fire extinguisher, and first aid kit on site
- Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet
- Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data
- Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit)
Benefits
- profit-sharing
Work Arrangement
Hybrid
Additional Information
- All other duties as assigned
- The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.
