Plan Coder (50456)

JOB DESCRIPTION SUMMARY

Position reports to the Supervisor Benefit Distribution & Installation and performs in-depth pharmacy and medical plan coding of new and existing business accounts. This position will ensure that all new and existing health (medical/dental/pharmacy) insurance plans underwritten by Western Growers Assurance Trust (WGAT) and those of Pinnacle Claims Management, Inc. (PCMI) are in compliance with the respective employers' summary plan descriptions.

DUTIES AND RESPONSIBILITIES

Plan Coding

• Plan code new business and plan changes.
• Verify new and existing plans loaded on the company's claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments.
• Respond to work orders received from examiners to investigate plan issues and irregularities.
• Evaluate testing requests for all new plans prior to loading them into the production system.

Administrative

• Keep a detailed log of open and completed work.
• Document resolutions to closed work orders.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
• Create and document a minimum of one new Standard Operating Procedure (SOP) annually.
• Identify, initiate and implement at least one process improvement and/or innovation annually.
• Maintain detailed log of plans that are currently being coded and in the process of being loaded.
• Send confirmations to internal stakeholders when applicable plans have been loaded. Work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS).

Other

• Utilize all capabilities to satisfy one mission - to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to perform this job's essential functions successfully. Reasonable accommodations 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 communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.

Qualifications

• BS/BA degree in computer science, business or related field and a minimum of two years of experience as a pharmacy, medical, dental claims auditor and/or plan testing experience, preferred.
• Exceptional ability to interpret summary plan descriptions of employee medical, dental, pharmacy benefits.
• Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demanding environment to meet expected goals, dates, and milestones.
• Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.
• Superior ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.
• Advanced skills in Microsoft Office applications, specifically word processing and spreadsheets.
• Demonstrated ability to analyze and comprehend complex issues, and personalities using independent judgment, leadership, tact, diplomacy, and initiative
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.