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Benefits Policy and Implementation Manager
Ref No.: 17-01903
Category: Permanent Placement
Location: Charlestown, Massachusetts
Job Description
The Benefits and Policy Implementation Manager leads business and operational efforts to develop detailed technical business requirements necessary for the implementation of the Plan's various benefit and product offerings. Using an in-depth knowledge of medical coding, reimbursement, clinical operations, and medical benefits, this individual will serve as the Plan's product and benefit expert and use this knowledge to ensure the efficient implementation of benefit plans while also serving as an internal resource for ongoing benefit interpretation for internal and external customers.
This position will provide leadership in the development of the Plan's Evidence of Coverage documentation, benefit related policies, and other benefit materials required to ensure compliance with state, federal, and other regulatory/accrediting organizations such as the Division of Insurance and NCQA. This individual also closely monitors state and federal legislative changes that have an impact on Plan benefits and develops implementation plans for addressing those issues.
Key Functions/Responsibilities:
  • Provides internal consulting services (i.e., benefit specifications, coding, and coordination between reimbursement, clinical management, and technical implementation) during the implementation of new products and benefits
  • Develops benefit policy documentation for providers and implements these policies throughout the organization
  • Serves as a benefit expert during the development and case installation of new products and benefit changes.
  • Leads the Benefit Administration Committee
  • Supports efforts to development the Plan's Evidence of Coverage and leads subsequent efforts to revise these documents, as well as other member contract materials in conjunction with the Plan's legal department
  • Develops and maintains benefit and coverage interpretative manuals and other associated documents used by Plan staff during daily operations
  • Leads interdepartmental projects and participates on interdepartmental committees pertaining to new technologies and medical policies
  • Develops implementation plans for new legislation affecting benefits and other benefit changes
  • Serves as the Plan's expert on benefit related legislation
  • Participates in the decision-making process and serves on committees responsible for individual member benefit extensions
  • Participates on the Plan's member appeals committee
  • Serve as the principle contact for benefit interpretation questions
  • Identifies and develop plans for communication to, and education of personnel about benefits and coverage issues
  • Leads interdepartmental teams organized to ensure the effective management of CPT/HCPCS and other transaction processing code implementation efforts
Supervision Exercised:
  • Co-manages the Plan's AAPC Project Xtern program requiring oversight of Certified Coding interns
  • Supervision Received:
  • Indirect supervision received regularly.
Qualifications:
Education:
  • Bachelor's Degree in Business, Health Care Administration, Public Health or related discipline
Preferred/Desirable:
  • Master's Degree Health Care Administration or Public Health
  • AAPC Certification
Experience:
  • Five (5) to seven (7) years experience in an HMO or other managed care setting with a focus on benefit design, product implementation, and/or regulatory compliance
  • Experience implementing new product lines within a managed care organization
Preferred/Desirable:
  • Consulting experience
  • Project management
  • Prior experience within an HMO, PPO or other health plan New Business Development department
Certification or Conditions of Employment:
  • Pre-employment background check
Competencies, Skills, and Attributes:
  • Experience working with commercial multi-product/multi-employer plans and benefit designs
  • Demonstrates strong organization skills and ability to work in a rapidly changing environment
  • Familiarity with government programs such as Medicaid or Medicare desired
  • Claims or other experience using industry standard coding
  • Experience applying analytical results to decision-making
  • Excellent team player with strong leadership skills
  • Must be able to effectively manage activities across multiple departments
  • Requires the capacity to clearly communicate complex issues and problems and escalate effectively
  • Detail oriented, excellent writing, proof reading and editing skills required
  • Must have a firm understanding of the managed care business structure, operations, and the ability to apply this knowledge to implement plan-wide policy changes
  • Must be able to understand and identify operational interdependencies between departments, particularly those leading contracts/rates, clinical coverage, benefits, and technical implementation
  • Co-manages the Plan's AAPC Project Xtern program requiring oversight of Certified Coding interns
  • Supervision Received:
  • Indirect supervision received regularly.
Qualifications:
Education:
  • Bachelor's Degree in Business, Health Care Administration, Public Health or related discipline
Preferred/Desirable:
  • Master's Degree Health Care Administration or Public Health
  • AAPC Certification
Experience:
  • Five (5) to seven (7) years experience in an HMO or other managed care setting with a focus on benefit design, product implementation, and/or regulatory compliance
  • Experience implementing new product lines within a managed care organization
Preferred/Desirable:
  • Consulting experience
  • Project management
  • Prior experience within an HMO, PPO or other health plan New Business Development department
Certification or Conditions of Employment:
  • Pre-employment background check
Competencies, Skills, and Attributes:
  • Experience working with commercial multi-product/multi-employer plans and benefit designs
  • Demonstrates strong organization skills and ability to work in a rapidly changing environment
  • Familiarity with government programs such as Medicaid or Medicare desired
  • Claims or other experience using industry standard coding
  • Experience applying analytical results to decision-making
  • Excellent team player with strong leadership skills
  • Must be able to effectively manage activities across multiple departments
  • Requires the capacity to clearly communicate complex issues and problems and escalate effectively
  • Detail oriented, excellent writing, proof reading and editing skills required
  • Must have a firm understanding of the managed care business structure, operations, and the ability to apply this knowledge to implement plan-wide policy changes
  • Must be able to understand and identify operational interdependencies between departments, particularly those leading contracts/rates, clinical coverage, benefits, and technical implementation