Program Manager Benefit Interpretation Specialist

7 days ago


Harrisburg, Pennsylvania, United States Jefferson Health Plans Full time
Program Manager, Benefit Interpretation

At Jefferson Health Plans, we are seeking a highly skilled and detail-oriented Program Manager, Benefit Interpretation to join our team. As a key member of our organization, you will be responsible for the direction, coordination, development, evaluation, and compliance of member benefits for all Jefferson Health Plans lines of business.

Key Responsibilities:
  • Primary subject matter expert in the interpretation of new and existing member benefits for all lines of business
  • Collaborate with the compliance team to ensure products are implemented according to existing and new regulations by line of business and industry standards
  • Analyze explanation of coverage documents to lead a multi-disciplinary group in determining the best approach for loading benefits offered, including member cost share and out-of-pocket maximums
  • Lead the definition of code sets used in benefits configuration and provider reimbursement
  • Interpret minimum regulatory requirements for prior authorizations to be used in benefits configuration
  • Collect and analyze data to assess and resolve operational obstacles to benefits design optimization
  • Serve as JHP's expert on benefit-related legislation
  • Maintain documentation necessary for systems analysts to configure benefits
  • Develop explanatory information for other departments to better understand benefits configuration across products
  • Cultivate collaborative and effective cross-functional relationships with key stakeholders, including sales, marketing, operations, compliance, healthcare management, and finance
Requirements:
  • Bachelor's Degree required and 5 years' experience in insurance industry in areas of Benefits Administration, Healthcare Management, or related field. RN and/or certified coder preferred
  • 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 healthcare and public policy
  • Demonstrated ability to lead and effectively work with multidisciplinary teams
  • Strong problem-solving skills
  • PC Skills (Word, Excel, PowerPoint)


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