You Make Us Grow. You Make Us Sharp.

Hours:

Shift Start Time:

8 AM

Shift End Time:

5 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Start time can vary.

Weekend Requirements:

As Needed

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$53.649 - $69.224 - $84.800

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
This position is responsible for managing, coaching and developing the Benefits Administration team across multiple lines of business (Medicare Commercial, Government, etc.) to ensure benefit plans are designed appropriately and consistently and performance guarantees, service level agreements and operational goals are met. Ensures benefit information is clear, accurate, consistent, and delivered timely to internal and external partners. This individual will serve as a subject matter expert on benefits, with responsibility for translating plan designs and policies (i.e., Certificates of Coverage) into detailed business requirements, ensuring benefits are implemented accurately and timely, investigating and responding to internal and external benefit inquiries, and supporting claims testing activities. Provides training to new and less experienced Benefit Administration team members. Assumes additional responsibilities in the absence of the Director.

Required Qualifications

• 5 Years in HMO or Health Insurance Management.
• 2 Years leadership experience working collaboratively across multiple functional areas (e.g., operations, configuration, clinical, IT, plan design) and fostering teamwork.
• Experience with spreadsheets, data reporting, and word processing applications.

Preferred Qualifications

• Other Course work or prior experience in education and training.
• 3 Years in a health insurance product implementation, benefit/coverage policy development, benefit configuration, or claims role.

Other Qualification Requirements

• Bachelor's degree in business, health services, or related field; or 4 years of relevant experience may substitute for degree. - Required

Essential Functions

• Leadership
  Display professionalism and teamwork in promoting the Mission, Goals and Objectives of Sharp Health Plan.
  Recruit, hire, motivates staff to perform at a level that consistently meets expectations.
  Develop, train, counsel staff, and conduct performance appraisals.
  Maintains a positive work environment that supports self-directed teams; provides a structure to optimize the experience, skill, knowledge and capability of the team; facilitates collaboration among team members.
• Benefit Development
  Oversees all translation of plan design strategy and policies (i.e., Certificates of Coverage) into detailed requirements for benefit configuration.
  Develops and documents workflows, systems requirements, process analysis and testing (including reasonableness checks). Providing efficient and cost-effective solutions as required.
  Oversees all claims testing and quality assurance activities and defect resolution.
  Identifies impact of solutions on existing and future systems. Identifies reporting needs based on system programming and workflows and oversees documents reporting requirements and testing of new reporting development prior to implementation to Production.
• Benefit Management
  Partner with Product Development, operational, clinical, and configuration teams to achieve benefit design solutions that align with plan design strategy and business requirements.
  Oversee development and documentation of policies and relevant background information for other departments to better understand plan designs and benefit intent. Manage all plans and benefits hand-offs to internal and external partners; develop and manage change control processes.
  Provide subject matter expertise to address escalated benefit inquiries and complex benefit-related issues. Identify opportunities to improve processes and build best practices for efficient and effective translation of product strategy/plan designs into configuration requirements leveraging new system capabilities or the integration of data/other applications into existing systems.
  Creates and maintains the necessary functionality in the benefit landscape, and workflows. Conducts root cause analysis, gathering data to pinpoint problem areas on which to focus. Recommends and implements solutions and evaluates results and implements controls to monitor consistent use of the solution.
• Training
  Coordinate continuing staff training to ensure Benefit Administrator education is sufficient to meet benefit compliance and establish quality and productivity standards to be reported monthly.
  Develop and maintain benefit administration policy and procedure manuals. Effectively communicate departmental policies to staff and other affected areas including updates to Knowledge articles used by Sharp Health Plan Customer Care staff.
• Data Validation
  Oversees the technical and administrative functions to lead the Benefit Administration team in organizational data validation projects to support major system enhancements, or release updates. Supports data validation activities when deploying changes to a large number of clients. Leads design of data validation processes to ensure data checks fall within an acceptable range to ensure compliance standards are met. Activities should automate data validation, improve quality, and reduce costs.
• Internal and External Customer Service
  Interface with Health Plans, Providers, Members, Medical Groups and Internal Sharp Health Plan departments to resolve issues in a professional manner that maintains consistently positive relationships. Demonstrates a positive, professional and contributory posture in all matters requiring interface with customers, both internal and external.
• Audits
  Manages responses to both external and internal audits. Ensures workflows support compliance and identifies when audit protocols need to be refreshed to more accurately capture day-to-day procedures. Evaluates audit findings and implements new processes to bring Plan Administration into compliance.

Knowledge, Skills, and Abilities

• Knowledge of health insurance or HMO operations with emphasis in the development or application of benefit interpretation guidelines, coverage policies, and/or reimbursement policies.
• Working knowledge and experience with medical coding (HCPCS, CPT, ICD-10)
• Excellent organizational and interpersonal skills.
• Ability to work effectively as a member of a creative management team.
• Knowledge of Federal and State regulations as related to benefit and claims adjudication.
• Adept at being an initiator of positive change to support the Mission, Values, and Goals of Sharp Health Plan.
• Ability to use data and analytical thinking to make fact-based decisions and/or recommendations.
• Solid problem-solving skills and ability to derive structure and clarity from ambiguous or open-ended inputs.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

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