POSITION SUMMARY:
The Plan Builder is responsible for the documentation, drafts, reviews and edits of the medical Summary of Benefits, Summary Plan Descriptions, and any amendments. This includes translating and the execution to implement, build, and maintain benefit plans, adjudication logic, benefit cross reference tables for clients, with the primary objective to optimize the system for automation and quality outcomes for end users. The Plan Builder will collaborate with Implementation and Client Management to ensure proper benefit design, make recommendations on design to improve automation and cost effectiveness, and data integrity for operational success for employer benefit designs.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Implement plan designs for existing and new clients.
Implement new functionality either within the system or with external vendors or both.
Identifies opportunities for areas of automation and works with appropriate business units.
Develops relationships with non-technical users that foster trust and collaboration.
Quickly understands existing business issues and data challenges.
Suggests areas for improvement in internal processes.
Effectively facilitates the release of systems with internal and external users.
Available during non-business hours to resolve system issues as needed.
Identify system issues, improvement opportunities, write enhancements, work with product and
engineering to implement products and enhancements for external and internal users.
QUALIFICATIONS:
This Plan Builder must be highly motivated and a self-starter. This individual must be a critical thinker and be able to grasp benefit concepts. The Plan Builder must be detail-oriented with the ability to manage multiple priorities and time-sensitive tasks with deadlines. Excellent client services skills including verbal and written communication skills along with strong interpersonal and problem-solving skills are required. This individual must also possess an ability to work collaboratively in a team environment. To perform the position, an individual must be able to satisfactorily perform each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required.
EDUCATION AND/OR EXPERIENCE:
It is required that individuals have completed a bachelor’s degree or have equivalent job experience.
Must have 3-5 years’ experience of extensive plan building supporting self-funded or fully-insured plans including Javelina application experience.
Must possess a strong knowledge of group medical claims coding, including ICD-10, HCPCS/CPT coding, HCFA 1500 and UB92.
A general understanding is required of compliance and regulatory issues including ERISA, HIPAA, ACA, COBRA and other applicable regulations.
CERTIFICATIONS/LICENSURE/REGISTRATIONS:
Preference will be given to individuals who have completed the CEBS (Certified Employee Benefits Specialist) or have obtained their life and health insurance license.
COMPETENCIES:
The Plan Builder should continue to develop the following competencies with an attitude of being a lifelong learner in the fields of employee benefits, insurance and business:
Client and Personal Service Knowledge of principles and processes for providing client and personal services. This includes client needs assessment, meeting quality standards for services, and evaluation of client satisfaction.
Developing Objectives and Strategies Establishing long-range objectives and specifying the strategies and actions to achieve them.
Fluency of Ideas The ability to come up with several ideas about a topic (the number of ideas is important, not their quality, correctness, and creativity).
Active Listening Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Problem Sensitivity The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
Establishing and Maintaining Interpersonal Relationships Developing constructive and cooperative working relationships with others and maintaining them over time.
Communicating with Internal and External Partners Providing information to partners within and outside the organization by telephone, in written form, e-mail, and in person.
Evaluating Information to Determine Compliance with Standards Using relevant information and individual judgment to determine whether events and processes comply with laws, regulations, and standards.
Organization Prioritizing workflows based upon client needs, deadlines (internal and external) and available resources; being capable of managing multiple projects at one time.
Judgment and Decision Making Considering the relative costs and benefits of potential actions to choose the most appropriate one.
Critical Thinking Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions and approaches to problems.
Complex Problem Solving Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Analyzing Data or Information Identifying the underlying principles, reasons, and facts of information by breaking down information and data into separate parts.
Updating and Using Relevant Knowledge Keeping up-to-date technically and applying new knowledge to your job.
Written Expression The ability to communicate information and ideas in writing so others will understand.
Written Comprehension The ability to read and understand information and ideas presented in writing.
Oral Expression The ability to communicate information and ideas verbally so others will understand.
Oral Comprehension The ability to listen to and understand information and ideas presented verbally.
Coordinating the Work and Activities of Others Getting members of a group to work together to accomplish tasks.
Mathematics Knowledge of arithmetic, algebra, statistics, and their applications.
Organizing, Planning, and Prioritizing Work Developing specific goals and plans to prioritize, organize, and accomplish your work.
COMPUTER SKILLS:
To perform this job successfully, an individual should have advanced proficiency in all Microsoft Office products and be able to learn new systems within a reasonable time. Javelina application experience is required.
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, walk, use hands and fingers, talk, and hear. The employee is frequently required to sit and reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, crouch or crawl. The employee must regularly lift and/or move up to 10 pounds and occasionally lift and/or move 25 pounds or more. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth
perception and ability to adjust focus.
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The employee will work both in an office environment and remotely from home during typical office hours with occasional overtime. The office environment has moderate temperatures and minimal noise levels. When working remotely the employee must have a quiet, office-like work environment suitable for phone and web calls, and strictly adhere to HIPAA and privacy regulations. Occasional travel may be required.
ADDITIONAL COMMENTS:
This job description is not intended to be a complete list of all responsibilities, duties or skills required for the job and is subject to review and change at any time, with or without notice, in accordance with the needs of Vitori Health LLC. Since no job description can detail all the duties and responsibilities that may be required from time to time in the performance of a job, duties and responsibilities that may be inherent in a job, reasonably required for its performance, or required due to the changing nature of the job shall also be considered part of the jobholder’s responsibility.