Job Posting for Program Manager Benefit Interpretation at Health Partner Plans, Inc.

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.
We offer Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We’re also committed to boosting the health of our community through outreach, education, and events. Founded over 35 years ago, Jefferson Health Plans continually develops new ways to encourage better health outcomes and has received national recognition for our innovations in managed care.
While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:

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

We are seeking a talented and enthusiastic Program Manager, Benefit Interpretation to join our team!

Working under minimal supervision responsible for direction, coordination, development, evaluation and compliance of member benefits for all Jefferson Health Plans lines of business. Uses in depth knowledge of medical coding, reimbursement, clinical operations, and standard benefits for public programs to ensure accurate and efficient implementation of benefit plans.

As the Program Manager, Benefit Interpretation your daily duties may include:

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

Qualifications

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.

Skills, We Value:

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)

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Program Manager Benefit Interpretation

Job Posting for Program Manager Benefit Interpretation at Health Partner Plans, Inc.

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