CareersPlan Builder/Auditor

Current Job Openings

Plan Builder/Auditor

Posting Date: 09/11/2019
Closing Date: Until Filled

Reports to: Plan Installation Manager
Non-Exempt

Responsibilities

           

SUMMARY:  

Is responsible for the maintenance of plan benefit set up and code direction utilizing plan installation documentation and selection tools. Ensures accuracy of plan set up using quality check out tool and testing processes.  Advises staff on system capabilities regarding benefit design and responds to Plan Building referrals. Is knowledgeable of the relationship between Plan Building and other claim and eligibility programs.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned:

  • Reviews Summary of Benefits and Coverage documents, plan documents and implementation documentation and completes plan installation tools for dental plans to accurately reflect plan benefit and coding intent. Expected timelines for completion: New Plans – 30 days, renewing plans – 15 days, mid-year plan changes and coding events – within project agreed upon timelines based on size and scope of project.
  • Audits dental plan fee schedules.
  •  Completes dental plan coding accurately and within the following timelines: New Plans – 15 days, renewing plans – 10 days, mid-year plan changes and coding events – within project agreed upon timelines based on size and scope of the project.  
  • Attains coding quality standard accuracy average of 95% or greater.
  •  Performs quality check   out and testing of Pool and ASO Medical, Dental and Vision benefit plan design accurately and within the following timelines: New Plans – 15 days, Renewing plans – 10 days, mid-year plan changes and coding events – within project agreed upon timelines based on size and scope of the project.  
  • Audits TML Health Benefits Pool selection lists, Universal and Plan screeners for correct coding decisions that compliment plan intent
  • Identifies and monitors plans and/or providers on recycle based on plan coding needs. Ensures claims are on removed from recycle promptly to minimize negative impact to other teams.
  • Performs accurate and timely audit and approval of Pool GLS (Group Level Screening) and Account Structure tools. Each month updates must be audited and approved; meeting timelines established by the OES (Online Enrollment System) calendar.
  • Demonstrates ability to identify and assist with the resolution of Member Database or coding inaccuracies that compromise accurate set up.
  • Creates and maintains P&Ps to document processes associated with functional responsibilities.
  • Identifies specific plan/system problems/inefficiencies and initiates workable solutions.
  • Maintains working knowledge of the OPI (Organizational Plan Indicator) and DCI (Direct Contract Indicator) network hierarchy ensuring plans are tied to the correct network selections.
  • Responds accurately and timely to Plan Builder claim referrals.  Interfaces with UMR Plan Installation team, Customer Specialist and Account Service Management as necessary to resolve referral. 
  • Effectively communicates with TML Health Benefits Pool Management, Marketing, line staff and UMR Plan Installation teams regarding system capabilities for benefit set-up, and plan design deficiencies that do not promote auto adjudication.
  • Performs Manager assigned ad hoc report. Provides analysis and able to inform and make recommendations based on data pulled.
  • Actively contributes with project decision making for functional responsibilities that lie within and outside of the Plan Building function
  • Draws conclusions from error trends identified and recommends correction in plan set up, additional training or process improvement as needed.
  • Special projects workgroup participant/Team lead for plan building and audit related project management whereby decisions made promote and support functional, organizational and Alliance goals and philosophies.
  • Mentors less experienced staff in plan building related functions.
  • Reviews future plan design for feasibility of set-up.
  • Effectively interfaces with TML Health Benefits Pool and UMR IT staff to test system/program upgrades


Qualifications / Skills Required

 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Extensive working knowledge of medical/dental/vision claim adjudication of multiple plan designs and managed care contracting, and/or plan building principles
  • Strong understanding of claim procedure and diagnosis coding principles
  • Ability to interpret and execute plan set up based on plan design documentation
  • Ability to utilize audit tools to assess accuracy of plan set up
  • Ability to prioritize work on hand to ensure established timelines are met
  • Ability to make independent decisions and draw conclusions from error trends identified
  • Ability to read, comprehend and carry out verbal or written instructions 
  • Ability to write simple correspondence Ability to effectively present information in one-on-one and small group situations to Members, Providers, and employees of the organization
  • Strong analytical ability
  • Strong organizational skills
  • Working knowledge of MS Office with an intermediate knowledge of Excel.

 

EDUCATION/EXPERIENCE:

Bachelor's degree from four-year College or university; or at least three years of extensive medical/dental/vision claims processing, claims auditing and/or plan building experience; or an equivalent combination of education and experience.

PHYSICAL/MENTAL REQUIREMENTS:

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 accommodations may be made to enable individuals with disabilities to perform the essential functions.

  •  Ability to maintain attendance and punctuality requirements
  • Ability to reach with hands and arms
  • Ability to sit for extended periods of time to read, write or use keyboard
  • Ability to repetitively enter data on keyboard and review information on CRT screen
  • Ability to speak/hear clearly to communicate by phone or in person
  • Ability to frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds 


To Apply
Please submit your resume with a cover letter to Human Resources. Indicate the position you are applying for and detail how you meet the qualifications listed. You may fax this information to (512) 719-6717, email us at Email Us, or mail it to:
TML Health
Attn: Human Resources
P.O. Box 140644
Austin, TX 78714-0644