Health Plan Specialist

The ideal candidate for the position of Health Plan Specialist has a passion for learning. If you are willing to learn, we are willing to teach you. Department members pride themselves on embracing continuous improvement. Candidates should have similar values. Applicants should feel comfortable acknowledging their mistakes and be able to learn and grow from them. Our emphasis is on progress over perfection. The department is a team that celebrates members’ wins and assists when members struggle.

Summary Description: Under the direction of the Vice President, Health Plans, oversees the day-to-day activities with Managed Care Organization Clients as well as assists with implementations of new clients. The person in this role interacts with all internal departments and supports extensive government reporting to ensure NVA’s compliance with requirements for government programs, including, but not limited to, Medicare, Medicaid, CHIP, PACE, and Health Insurance Exchanges in addition to state and ERISA regulations for commercial programs. The position also provides support for resolving member and provider complaints and appeals.

Essential Duties & Responsibilities:

• Review of state managed care manuals and regulations for updates and report on same
• Review of state and federal fee schedules for updates and coordinates claims department to update internal fee schedules accordingly.
• Researches and responds to internal Call Center Representatives regarding member complaints, appeals and inquiries. Assures responses are provided according to regulatory guidelines, service level agreements, or internal standards.
• Acts a liaison between client and internal departments to resolve issues raised by the clients
• Prepares performance measurement reports in the format required by government agencies, regulatory bodies or accrediting bodies and ensures performance standards are being met.
• Drafts or revise desktop processes, policies and procedures as needed
• Builds and maintains effective professional relationships with clients.
• Assists with resolving pre- and post-implementation issues between clients and internal operations and support the implementation of all new health plans.
• Identify areas of concern that may compromise client satisfaction through data analysis, and propose solutions based on findings.
• Manages, updates, and maintains source data libraries as they relate to processes.
• Provides training and development activities with Member Services and Claims.
• Attends client meetings as directed.
• Attend client broker or open enrollment events, as needed
• Performs all other duties as assigned.
  
  

Qualifications:

• Proficient in Office 365 applications including Word, Outlook, Teams, PowerPoint, with a particular emphasis on Excel. Should understand the basics of Pivot Tables, Power Pivot/Data Model, Power Query/Get & Transform.
• Two years’ experience in administering health insurance benefits, call center, claim adjudication or reporting preferred.
• Read and comprehend federal and state statutes and regulations as well as client requests and inquiries.
• Candidate must show potential to develop high level written communication skills including:
• Draft clear and concise email correspondence
• Identifying and addressing all issues and concerns in responses to clients
• Accurately summarize events, compliance standards, requirements to both internal and external constituencies.
• Candidate must show potential to develop high level critical thinking and problem-solving skills, including proper problem identification and root cause analysis.
• Must have the ability to coordinate the development and implementation of multiple projects at one time, organizing tasks and deliverables needed to meet the objectives and timeliness established for the programs.
• Must be able to adapt to rapidly changing priorities
• Empathy for clients and members required.