PLAN DESIGN AND CONTRACT SPECIALIST (FULL-TIME EXEMPT SALARY / REMOTE / HYBRID)
This is a full-time position with a hybrid remote work arrangement in our Sheboygan, WI location. No weekends, holidays or on-call rotations. Ideal candidate will work in Wisconsin.
Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees. We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence.
JOB SUMMARY
The scope of this position is to develop, maintain and test benefit plans specifically related to their adjudication logic with in the Healthpac System while meeting Clients’ needs as requested within their written summary plan documents for Medical, Dental, Vision, and Workers Compensation policies. Additionally, this position builds and updates work flow rules and queues to manage claim flow through the system and for the accurate routing of claims to the appropriate site for specific reviews or PPO routing.
SUMMARY OF ESSENTIAL JOB FUNCTIONS
- Create and maintain benefit plans in the system as per the plan documents assigned.
- Work with the Claims Department to develop strategies to manage specific issues regarding individual plans and ensure claims are adjudicating and routing as expected.
- Research current regulations from multiple sources to ensure our plans are compliant.
- Maintain and monitor workflow
- Review and research all new CPT, ICD10, and HCPCS codes annually and update logic and categories accordingly for correct payment/processing.
- Test new software releases for potential issues in functionality.
- Perform high level customer service in regard to the benefit plans implementation and ongoing maintenance. Work with Account Management staff and Sales Staff to achieve unusual and unique plan set-ups requests when possible.
- Works on network service needs for new and existing plans.
- Troubleshoot any contract pricing disagreements with providers
- Initiate and manage set-up for monthly PPO access and network fees.
- Test new software releases for functionality or impending concerns.
POSITION REQUIREMENTS
Education and Experience
- Minimum of one year of successful experience in health insurance claims or operations function.
- Associates Degree in business and/or equivalent industry preferred
Specific Technical Knowledge and or Certifications related to the Position
- Proficient in Microsoft Office, Healthpac Computing System, and extensive knowledge of plan loading.
- Background in medical coding and billing relating to HCPCS, CPT, and ICD10 codes.
- Full understanding of claims and eligibility functions as well as PSE operations.
POSITION RELATED COMPETENCIES
• Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
- Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
- Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
- Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
- Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
- Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.
PHYSICAL DEMANDS / WORK ENVIRONMENT
This is sedentary position which requires the individual to sit for long periods of time and the proper positioning/posturing for extensive viewing of computer screens and computer related work is required. It is encouraged that individuals intermix this sedentary time with periodic movement within one’s office space and/or to other office areas to counteract the sedentary nature of this position.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
To the selected candidate, we offer:
Competitive compensation based on experience and a comprehensive benefit package provided to include Medical, Dental, Vision, Life, STD/LTD, FSA, Paid Time Off, personal days, 401k with match, wellness and exercise membership and more. Click HERE to view our full-time benefits flyer.
Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.
If this sounds like you and you’re seeking career growth with an exciting new career path in overseeing the quality of health care for our clients and their members, please send your cover letter and resume following the instructions for this site.
Prairie States Enterprises
Equal Opportunity Employer
