Benefits & Coding Administrator

Job Description:

Benefits & Coding Administrator

This is a remote role that can be done from most US states.

Reporting to the Manager, Benefits Administration, the Benefits & Coding Administrator II works with the Benefits Administration Team to support the accurate and effective implementation of benefits across all products.

ESSENTIAL FUNCTIONS
• Evaluate benefit configuration in collaboration with IT Configuration and Claims staff, ensuring that benefit configuration aligns with the approved business requirements and plan materials.
• Contribute to business discussions re: benefit coverage and configuration, drawing on claims experience, knowledge of regulatory requirements, industry standards re: coding and billing, and payer benchmarking for ad hoc and system-wide decisions.
• Support the maintenance and enhancement of benefit information in KCII (Knowledge Center II).
• Represent Benefits Administration as a subject matter expert on corporate projects, committees or workgroups.
• Provide technical business summaries on selected benefit topics in support of work required to develop and maintain benefits as required for specific program and plan requirements.
• Provide research and benchmarking on services and items represented by new codes as released quarterly; leading the code load process including the presentation at the Benefit & Coding Committee and business requirements submission to IT Configuration
• Lead coding and coverage discussions on operational work and selected projects; working with colleagues from key areas including: Product Management, Compliance, Provider Reimbursement, Provider Payment Integrity, IT Configuration, Clinical, Pharmacy, Customer Service and Claims.
• Contribute to benefit property development or modification in the integrated care administrative transaction system (QNXT) by coordinating business requirements with configuration requirements.
• Monitor the accuracy of benefit information in member materials, working with the Product Management team and other stakeholders as needed.
• Work with Benefits Administration Team to maintain the accuracy of benefit information provided to internal teams via the Benefit Clarification process and the Knowledge Center application.
• Enhancing KCII (Knowledge Center II) to support more efficient communication of benefit coverage; collaborating with Customer Service on updates.
• Maintain the Code Search Look Up feature with quarterly updates and benefit changes.
• Evaluate the Benefit Clarification Library to identify prioritized updates for QNXT and/or KCII.
• Participate in Benefit & Coding Committee meetings and other meetings as assigned.
• Hold self and others accountable to meet commitments.
• Build strong customer relationships and deliver solutions that meet customer expectations; establish and maintain effective customer relationships – both internal as well as external.

Qualifications

Required:

• Certified Professional Coder (CPC) certification required or experience with and an understanding of ICD 9, ICD 10, CPT, HCPCS codes along with other claims billing requirements.

• Associate’s Degree in health science administration, business, or healthcare-related field.

• At least 3 years of experience in valuing the impact of benefit coverage decisions with the support of analytics preferred.

• At least 3 years of experience in a related role required.

Preferred/Desired:

• Bachelor’s Degree.

• Knowledge of and experience with Medicare Advantage plan coverage.

• Knowledge of and experience with Dual Eligible-Medicare/Medicaid/DSNIP plan coverage.

• Knowledge of and experience with Medicaid health insurance products.

• Knowledge of Commercial health insurance products.

• Knowledge of and experience with QNXT claims processing system.

• Knowledge of and experience with medical claim analysis.

• Knowledge of health insurance contracts and benefits, managed care products, Medicare products, HMO, PPO or health insurance benefit design.

• Working knowledge of healthcare regulation at a State and Federal level.

SKILLS/COMPETENCIES

• Excellent technical skills including ability to navigate the Microsoft suite of products (i.e., WORD, EXCEL, and Sharepoint).

• Excellent written and oral communication skills including technical writing for cross-functional teams.

• Ability to prioritize work and operate under tight deadlines.

• Demonstrate the organization's Core Values of Accountability, Service Excellence, Quality Care, Diversity, and forging strong Relationships.

• Respect the talent and unique contribution of every individual, culture, and ethnic group and treat all people in a fair and equitable manner.

• Exercise self-awareness; monitor impact on others; is receptive to and seek out feedback; use self-discipline to adjust to feedback.

• Accountable for delivering high-quality work. Act with a clear sense of ownership.

About Us:

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.