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Product Benefit Administration Specialist

WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294329)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Product Benefit Administration Specialist is responsible for day-to-day benefit/product administration operations, ensuring the alignment of business processes and decisions with the benefit/product strategy as well as ensuring compliance from a benefit perspective including the development and management of Evidence of Coverage (EOC), Product Contract Documents, Member Handbooks, Schedules of Benefits (SOBs), Schedule of Benefit and Contract documents (SBC), etc., as well as ensuring compliance from a claims configuration and adjudication perspective.

Key Functions/Responsibilities:

• Supports, develops and maintains the EOCs, SOBs, SBCs, Covered Services Lists, amendments, handbooks and all internal benefit resource documentation for all products.

• Using an in-depth knowledge of Medicare, Medicaid, Commercial (HMO, PPO and POS), and other state and federal regulatory requirements, including product specific contracts, clinical operations and medical benefit requirements, this individual will serve as

the Plans product and benefit expert for the product(s) they represent.

• Support all implementation steps needed to support mandated changes, internal benefit changes, new codes, and new employer-group specific benefit designs for both internal and external information.

• Closely monitor state and federal legislative changes that have an impact on Plan benefits, policies and develop implementation plans for addressing such issues.

• Support operational issues related to benefits, new mandates or contract changes with regulatory products.

• Serve as the primary liaison between the internal product managers/external partners and the plan supporting benefit questions and ad-hoc inquiries and requests as they relate to contract, configuration, adjudication, and regulatory submissions.

• Participate as a benefits subject matter expert (SME) on cross-functional, operational teams such as (Reimbursement Policy, Clinical Operations Subgroup, CCB, Claims Payment Subgroup etc.).

• Other responsibilities as assigned.

Supervision Exercised:

• None

Supervision Received:

• General supervision received weekly and as needed.

Qualifications:

Education Required:

• Please see education preferred

Education Preferred:

• Bachelor’s Degree in Business Administration, Public Health Administration, Public Policy or a related field. The equivalent combination of training and experience acceptable.

Experience Required:

• Minimum of 3-5 years in the Healthcare industry, particularly in positions that are familiar with product and or regulatory compliance is required.

• Experience with commercial, Medicaid, and/or Medicare. Medicare experience preferred.

Experience Preferred/Desirable:

• Experience working with Medicaid, Medicare and commercial coding rules/ regulatory requirements.

• Experience working with ICD-10 and CPT coding principles.

• Medical claims processing experience.

Required Licensure, Certification or Conditions of Employment:

• Successful completion of pre-employment background check.

Competencies, Skills, and Attributes:

• Effective collaborative and proven process improvement skills.

• Strong oral and written communication skills; ability to interact within all levels of the organization.

• A strong working knowledge of Microsoft Office products.

• Demonstrated ability to successfully plan, organize and manage projects.

• Detail oriented, excellent proof reading and editing skills.

• Strong analytic skills in terms of ability to interpret regulations and assess impact to products, configuration, etc.

• Ability to work independently and collaboratively, manage multiple projects and meet scheduled deadlines.

• Demonstrates strong organization skills and ability to work in a rapidly changing environment.

• Familiarity with government programs such as Medicare.

• Claims or other experience using industry standard coding.

• Experience applying analytical results to decision-making.

• Must be able to understand and identify operational interdependencies between departments, particularly those leading contracts/rates, clinical coverage, benefits, and technical.

Working Conditions and Physical Effort:

• Ability to work OT during peak periods. (Non-Exempt Positions)

• Regular and reliable attendance is an essential function of the position.

• Work is normally performed in a typical interior/office work environment.

• No or very limited physical effort required. No or very limited exposure to physical risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294329)

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According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not reach out to individuals via text, we do not ask or require downloads of any applications, or “apps”, and applicant screenings, interviews and job offers are not conducted over text messages or social media platforms. We do not ask individuals to purchase equipment for, or prior to employment. To avoid becoming a victim of an employment offer scam, please followthese tips from the FTC (https://consumer.ftc.gov/consumer-alerts/2023/01/looking-job-scammers-might-be-looking-you?utm_source=govdelivery) .