Program Manager Benefit Interpretation

Philadelphia, PA, USA Req #1585

Monday, October 30, 2023

Why Choose Jefferson Health Plans?
We are an award-winning, not-for-profit health maintenance organization. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

We offer Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We're also committed to boosting the health of our community through outreach, education, and events. Founded over 35 years ago, Jefferson Health Plans continually develops new ways to encourage better health outcomes and has received national recognition for our innovations in managed care.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:

• Competitive Compensation Packages including 401(k) Savings Plan with Company Match and Profit Sharing 
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off 
• Impact on the communities we service 

We are seeking a talented and enthusiastic Program Manager, Benefit Interpretation to join our team!
Working under minimal supervision responsible for direction, coordination, development, evaluation and compliance of member benefits for all Jefferson Health Plans lines of business. Uses in depth knowledge of medical coding, reimbursement, clinical operations, and standard benefits for public programs to ensure accurate and efficient implementation of benefit plans. 
As the Program Manager, Benefit Interpretation your daily duties may include: 

• 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

Qualifications 

• 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.

 Skills, We Value: 

• 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)