The Product/Benefit Administration Specialist is responsible for day-to-day benefit/product administration operations, ensuring the alignment of business processes and decisions with the benefit/product strategy as well as ensuring compliance from a benefit perspective including the development and management of Evidence of Coverage (EOC), Product Contract Documents, Member Handbooks, Schedules of Benefits (SOBs), Schedule of Benefit and Contract documents (SBC), etc., as well as ensuring compliance from a claims configuration and adjudication perspective. Under the direction of the Director of Product/Benefit Administration the Product/Benefit Administration Specialist will develop and oversee the communication of all state and federal regulatory benefit changes needed for the products they administer as well as the execution and implementation of these benefit changes and deliverables, lead the resolution of cross-functional business process and procedural changes needed and serve as the primary benefit liaison both internally and externally with state and other regulatory agencies, and interfaces with state and federal systems, including but not limited to HIOS, SERFF, HPMS, and any other technical interfaces as needed.
The following key functions/responsibilities apply to this position:
Leads business and operational efforts to develop and maintain detailed technical business requirements such as the Business Rules Document(s) necessary for the implementation of plan and product offerings.
Using an in-depth knowledge of Medicare, Medicaid, Commercial (HMO, PPO and POS), and other state and federal regulatory requirements, clinical operations and medical benefit requirements, this individual will serve as the Plans product and benefit expert for the product(s) they represent.
Leads, develops and maintains the EOCs, SOBs, SBCs, Covered Services Lists, amendments and handbooks for all products such as MH including ACO, MCO, SKSC, NH, QHP, SCO, etc.
Quality checking the brochures, SOBs, member materials, etc., created and maintained by Marketing.
Develop, implement and lead the development and annual review of the Benefit Coverage Summaries. This will involve a close working relationship with the Director of Product Administration, Payment Policy and Reimbursement, Medical/Clinical Policy and Configuration to ensure proper policy alignment as well as configuration and procedure coding of all benefits, including benefit rules, etc., for correct claims adjudication.
Develop and lead all implementation steps needed to support mandated changes, internal benefit changes, new codes, and new employer-group specific benefit designs
Closely monitor state and federal legislative changes that have an impact on Plan benefits, policies and develop implementation plans for addressing such issues.
Develop and submit any regulatory product submission and respond to regulatory inquiries.
Accountable for ensuring cross-functional communication to assess risk, complexity and strategic planning for implementation.
Track competitive benefit information
Facilitate and lead the Benefit Administration Team
Lead, oversee, track, and document operational issues related to benefits, new mandates or contract changes with regulatory products (MH, ACO, MCO, QHP, NH, SCO etc.)
Serve as the primary liaison between the internal product managers/external partners and the plan supporting benefit questions and adhoc inquiries and requests as they relate to contract, configuration, adjudication, and regulatory submissions
Communicate with and to other business areas when there are issues with benefits and proposed fixes to ensure there are no further problems.
Subject Matter Expert
Provides internal consulting services during implementation of benefits (benefit specifications, coding, and coordination between reimbursement, clinical management, and technical implementation)
Participate as a benefits subject matter expert (SME) on cross-functional, operational teams (Reimbursement Policy, Clinical Operations Subgroup, CCB, Claims Payment Subgroup etc.)
Support, from a QC perspective, the data being displayed on the member/provider portals, external web-site, ID card descriptions, and other member-facing materials, reflecting any benefit or product-specific information that is created and maintained by Marketing
Partnering with the product manager in understanding the product rules, requirements, etc., and reflecting those in the member-facing materials, such as the Evidence of Coverage, Handbook, Schedule of Benefits, Schedule of Benefits and Coverage, Covered Services Lists, etc. as well as the BRD
Represent a company-wide resource in terms of benefit-related questions, issues, etc. including the submission of Service Now tickets for needed system configuration corrections, including the development and review of User Acceptance Testing
Train/develop presentations on new benefits/products., etc., and roll-out in variety of ways, depending on need (e-learning, round table discussions, formal trainings, etc.)
Respond to External Requests such as RFPs, regulatory questionnaires, EQRO, Ernst & Young audits, etc.
Contract and Regulatory Knowledge
Maintain a thorough understanding and knowledge of all operational, contractual and regulatory requirements for the products they are managing (MH, MCO, ACO, QHP, NH, SCO, etc.)
Review the product contracts annually, or when amended, to ensure we are in compliance from a benefit, coding, configuration and adjudication perspective (end to end)
Identify codes that map to particular benefits, including CPT, HCPCS, REV, Provider Specialty, Bill Type, Modifiers, ICD-10 Diagnosis Codes, etc.
Maintain the coding matrix, for all products, along with the Benefit Categories for all products
Provide code updates on a quarterly basis by identifying coverage, benefit categories, cost-sharing, business rules, and meet all necessary deadlines
Bachelor's Degree in Business Administration, Public Health Administration, Public Policy or a related field. Candidates who do not meet the educational requirement but possess the appropriate combination of training and experience will be considered.
Minimum of 3-5 years in the Healthcare industry, particularly in positions that are familiar with product and or regulatory compliance is required
Minimum of 3-5 years experience with commercial, Medicaid, and/or Medicare plans preferred.
Experience with the following is preferable: either consulting or project management experience, prior experience within an HMO, PPO or other health plan New Business Development department, and prior experience within a Medicare Advantage, FFS, or other, organization and/or a Medicaid Managed Care Organization
Competencies, Skills, and Attributes:
Knowledge of Medicare regulations including NCDs, LCDs, etc., and how to implement them within a Managed Care Organization
Knowledge and experience working within a commercial organization with multi-product/multi-employer plans and benefit designs
Effective collaborative and proven process improvement skills.
Strong team player
Strong oral and written communication skills; ability to interact within all levels of the organization.
A strong working knowledge of Microsoft Office products.
Demonstrated ability to successfully plan, organize and manage projects
Detail oriented, excellent proof reading and editing skills.
Strong analytic skills in terms of ability to interpret regulations and assess impact to products, configuration, etc.
Ability to work independently and collaboratively, manage multiple projects and meet scheduled deadlines
Demonstrates strong organization skills and ability to work in a rapidly changing environment
Familiarity with government programs such as Medicare and/or Medicaid
Claims or other experience using industry standard coding
Experience applying analytical results to decision-making
Must be able to understand and identify operational interdependencies between departments, particularly those leading contracts/rates, clinical coverage, benefits, and technical
Remote Tele-worker position is available.
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.