Responsibilities
- Plan code new business and plan changes.
- 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.
- Respond to work orders received from examiners to investigate plan issues and irregularities.
- Evaluate testing requests for all new plans prior to loading them into the production system.
- Keep a detailed log of open and completed work
- Document resolutions to closed work orders.
- Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
- Create and document a minimum of one new Standard Operating Procedure (SOP) annually.
- Identify, initiate and implement at least one process improvement and/or innovation annually.
- Maintain detailed log of plans that are currently being coded and in the process of being loaded.
- Send confirmations to internal stakeholders when applicable plans have been loaded.
- Work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS).
- 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.
- All other duties as assigned.
Requirements
- Exceptional ability to interpret summary plan descriptions of employee medical, dental, pharmacy 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.
- Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.
- Superior ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.
- Advanced skills in Microsoft Office applications, specifically word processing and spreadsheets.
- Demonstrated ability to analyze and comprehend complex issues, and personalities using independent judgment, leadership, tact, diplomacy, and initiative.
Nice to Have
- BS/BA degree in computer science, business or related field and a minimum of two years of experience as a pharmacy, medical, dental claims auditor and/or plan testing experience.
Benefits
- competitive compensation packages
- premier investment support
- enriching personal development
- flexible work arrangements with work-from-home, in-office or hybrid options
- profit-sharing
Work Arrangement
Hybrid
Additional Information
- There isn’t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee’s life.
