Provides support for significant Medicare and Exchange product and benefit initiatives. This includes new product offerings as well as support for business migrating from legacy platforms. Successful candidates will have a mix of product and benefits knowledge and it's use in claims adjudication processing. If your goal is to combine your strong knowledge product/benefit knowledge, Medicare or Exchange, with a bent for analytic and technical implementation, then this is the ideal job for you. You will determine the best approach for driving the desired benefit outcomes in claims processing and provider payment. Experience with coding standards, ICD 10 and CPT codes would be beneficial. You will also need to evaluate the impact of CMS and state legislation on benefit plans. This is a unique opportunity to be on a dynamic Team that is shaping the new delivery of healthcare. Prior knowledge and experience with the Health Edge Health Rules Payor platform and HRL Language for complex benefit configuration is highly desired.
May independently manage midsize product enhancements.
Demonstrated analysis and critical thinking and skills, with strong knowledge of product and benefit plan configuration on a business owned and maintained platform. Ideal candidates understand the interaction of benefits, provider networks and claims adjudication outcomes.
Represents Medicare NextGen Product and Benefit Configuration capabilities and strategy in cross functional meetings and related project activities, e.g. Medicare Product and Marketplace Offerings for Individual and Group bid filings, Legislative Review Committee, and Operational Support areas.
Collaborates with market segments to develop and implement plans and product features to achieve segment product strategies and achieve marketplace advantage.
Serves as project manager and/or participant for selected projects.
Independently manages mid-sized product enhancements, including defining new enhancement requirements and feature with the application vendor.
Ensures that the Product & Benefit configurations are designed, developed, implemented and maintained from a product and business/customer point of view.
Ensures maximum reusability across standard plans and offerings to enable efficiency and accuracy in delivery and speed to market.
Performs research and analysis on legislative, competitive and industry issues to recommend new products or product enhancements.
Participates in idea generation and project vision session for the development of new products and product enhancements.
Gathers and analyzes feedback in support of performance analysis for products and continual improvement.
Participates and/or facilitates cross enterprise work group sessions to support individual and group bid process and subsequent delivery of Medicare products and benefit plans for Open Enrollment and claims adjudication and servicing.
This is a work at home position and can be worked from any U.S. location. Training period in the office may be required.
In-depth understanding of the Medicare regulatory environment and impacts to benefits and claims adjudications.
Knowledge of claim handling and associated processes such as provider contracting.
Strong analytical skills.
Proficiency with Excel.