To support contractual leadership & expertise to the contract administration department by taking responsibility for the coordination, implementation & administration of the Region’s contracts & benefits which include:
- Participating in cross-functional work efforts related to the clarification, interpretation, benefit administration, pricing activities & medical policy development &
- Creating written materials used to communicate w/ regulators & internal stakeholders.
Essential Functions:
- Is responsible for on-going development & administration of Health Plan membership contracts & related documentation for an assigned product segment.
- Develops filing strategies & secures regulatory approval w/ the appropriate Depts of Insurance. Monitors & tracks progress to approval. Maintains positive working relationship w/ regulators.
- Ensures the accuracy & compliance of all regulatory filings related to the assigned product segment.
- Is responsible for ensuring the issuance of all the HP’s group, non-group, & ancillary benefit plans, contracts, forms & evidence of coverage (for both new products & existing products) in accordance to regulatory statues & timelines.
- Oversees the on-going administration of the region’s Federal contract w/ the Office of Personnel Mgmt including the annual benefit submission & on-going reports. Maintains relationship w/ OPM on a local level.
- Is responsible for developing & implementing policies & guidelines related to benefit & contractual interpretation w/ the MG & Regional Administration.
- Serves as the primary resource for resolution of benefit & contractual clarification issues. Familiar w/ ICD 9, CPT & other benefit classification/coding tools to ensure appropriate medical definition & benefit rules.
- Provides strategic input into the benefit designs for products such as POS, OOA, Medicare, Self funding, etc. to expedite regulatory filing & approval cycle.
- Collaborates w/ department responsible for configuration of systems to reflect accurate benefit info.
- Manages all functions related to the filing, & member contractual issuance for the assigned product segment.
- Manages & implements Federal & State regulatory requirements & laws as they relate to HP benefits & contracts to assure compliance in all jurisdictions.
- Identifies & articulates problems & formulates responses w/out precedents.
- Is responsible for analysis, communication & dissemination of information on benefits & contracts of the assigned product segment & establishing guidelines for administration of such w/in the Region for both administrative & MG mgrs.
Qualifications:
Basic Qualifications:
- 5 years of experience in progressively responsible mgmt positions, of which 2 years must be in leading complex, interdisciplinary projects to timely completion required.
- 2 years of experience in regulatory/legal activity required.
- Bachelor's degree in Mktg, Healthcare, or related field required.
- Excellent written & oral communications skills required.
- Demonstrated ability to effectively use PC &/or mainframe computers required.
- Knowledge of current hlth care mktplace dynamics & KP position in the mkt required.
- Knowledge of non-KP health insurance products, rating methodologies, & strategies required.
- Working knowledge of Federal HMO Laws & Regulations; OPM/FEHB Regulations; MD & VA HMO Laws & Regulations; Federal TEFRA, COBRA, & Medicare Laws & Regulations; & Maryland COBRA Laws & Regulations required.
Preferred Qualifications:
- Master’s degree preferred.
- Health care, benefits, &/or insurance experience preferred.
- Knowledge of medical terminology, benefit coding, & clinical procedures preferred.
- Knowledge of project mgmt, spreadsheets, presentation graphics, & word processing preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.