Program Manager Benefit Interpretation Specialist

3 days ago

Scranton, Pennsylvania, United States Jefferson Health Plans Full time
Job Title: Program Manager Benefit Interpretation

At Jefferson Health Plans, we are seeking a highly skilled and experienced 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
  • 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
Requirements:
  • 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
  • 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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