Job description

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Job Description

The Product/Benefit Administration Specialist is responsible for day-to-day benefit/product administration operations, focusing on our Medicare products such as Medicare Advantage, Senior Care Options (SCO), etc., 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.

Key Functions/Responsibilities: The following key functions/responsibilities apply to this position:

• Member Materials:
• 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
• Benefit Oversight
• 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)
• Coding Knowledge
• 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

Must-Haves

• 3-5 yrs experience Medicaid or Medicare Plan experience
• 3-5 yrs product and/or regulatory compliance experience
• Product Documentation experience (Evidence of Coverage, Member Handbooks, Schedule of Benefits, etc.)

Job Type: Full-time

Schedule:

• Evening shift

Application Question(s):

• DO YOU HAVE 3-5 YRS EXPERIENCE MEDICAID OR MEDICARE PLAN EXPERIENCE ? PLEASE COMMENT
• DO YOU HAVE 3-5 YRS PRODUCT AND/OR REGULATORY COMPLIANCE EXPERIENCE ? PLEASE COMMENT, EXPLAIN
• DO YOU HAVE PRODUCT DOCUMENTATION EXPERIENCE (EVIDENCE OF COVERAGE, MEMBER HANDBOOKS, SCHEDULE OF BENEFITS, ETC.) ? PLEASE CONFIRM
• PLEASE SHARE YOUR E-MAIL ADDRESS AND YOUR ZIP CODE
• ADDITIONAL INFORMATION YOU WOULD LIKE THE EMPLOYER TO KNOW ?

Work Location: Remote

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