Self-Funded Medical Plan Builder

Job Summary

We are seeking a Self-Funded Medical Plan Builder to serve as a key link between IT capabilities and business objectives. This role is responsible for building, maintaining, and optimizing medical and dental plan configurations within the claims system. The ideal candidate will lead initiatives to enhance claims auto-adjudication, assist with system conversions, and ensure plan builds are streamlined and efficient.

This position offers an opportunity to leverage technical expertise and analytical skills to improve healthcare claims processes and support business objectives. If you have a passion for optimizing systems and driving efficiencies in medical plan administration, we encourage you to apply.

Why Join Us?

• Career Growth & Development: This role offers a unique opportunity to expand your technical expertise in medical plan building, coding, and regulatory compliance. With structured training and mentorship, you’ll develop highly specialized skills that set you apart in the healthcare industry.
• Make a Meaningful Impact: Your work will directly enhance the accuracy and efficiency of claims processing and plan administration, ensuring better outcomes for clients and members. You’ll play a key role in optimizing processes and improving healthcare plan functionality.
• Innovative & Supportive Environment: Join a team that values continuous improvement, collaboration, and innovation. You’ll work with experienced professionals who are dedicated to sharing knowledge and supporting your success.
• Competitive Compensation & Benefits: We offer a comprehensive benefits package, competitive salary, and professional development opportunities to help you excel in your career.
• Challenging & Rewarding Work: If you thrive in problem-solving, analytical tasks, and technical learning, this role will keep you engaged and constantly growing. Your investigative mindset and attention to detail will be highly valued and utilized daily.

If you're looking for a dynamic role with growth potential in the healthcare industry, we encourage you to apply and take your career to the next level!

Who You Are:

• Analytical & Detail-Oriented: You have a keen eye for spotting errors, inconsistencies, and areas for improvement in medical plan structures and claims processing.
• Investigative & Problem-Solving Mindset: You enjoy digging into complex issues, identifying root causes, and implementing solutions to optimize claims accuracy and efficiency.
• Tech-Savvy & Eager to Learn: You have experience with claims processing systems and a strong desire to expand your technical skills, including medical coding (ICD-10, CPT, HCPCS) and plan building.
• Regulatory & Compliance-Minded: You understand (or are eager to learn) federal and state health regulations, ensuring that medical plans adhere to industry standards and compliance requirements.
• Self-Motivated & Independent: You take initiative, manage your workload effectively, and thrive in an environment where you can drive process improvements and efficiency.

Key Responsibilities

• Build and revise medical and dental plan configurations, optimizing for efficiency and accuracy.
• Interpret a Summary Plan Description and translate into a plan profile to facilitate the system setup process.
• Lead projects to improve claims auto-adjudication and provider data integrity.
• Analyze data and provide strategic recommendations.
• Research and resolve complex claims inquiries.
• Identify benefit design changes and provide recommendations to increase customer auto-adjudication rates.
• Provide technical assistance and training for claims processors, including developing training materials. Assign role-based security measures.
• Support Stop Loss tracking and ensure compliance with federal and state health regulations.
• Conduct quality assurance testing and define configuration specifications.
• Develop reporting tools, analyze technical issues, and recommend solutions.

Qualifications

Experience:

• 5 years of experience in medical plan building, claims processing, or health insurance, preferably in a TPA or managed care environment.
• 5 years of experience in business/systems analysis, quality assurance, or a related technical field.
• Health insurance industry experience required.

Education:

• Bachelor’s degree in IT, Computer Science, or a related field preferred.
• : CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) preferred.

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• Expertise in ICD-10, CPT, and HCPCS coding.
• Strong understanding of federal and state health regulations.
• Experience with claims processing and adjudication systems.

Soft Skills:

• Self-directed, analytical, problem-solving, inquisitive, and strong communicator with a continuous improvement mindset.

About Foundation for Medical Care & HealthEdge Administrators

Foundation for Medical Care of Kern County/HealthEdge Administrators was founded more than 60 years ago and is located in Bakersfield, CA. FMC/HealthEdge works directly with brokers, consultants, general agents and insurance companies to provide the most appropriate healthcare solutions to our clients, concentrating our efforts in each of the communities we serve. We are a small business that is customer-centric, agile, supportive, and with an engaging culture. We envision ourselves as a trusted leader in our healthcare community, demonstrating performance excellence to our employees, providers clients and business associates.

Our work environment includes:

• Modern office setting
• Work-from-home days
• Growth opportunities
• On-the-job training
• Relaxed atmosphere
• Regular social events

Foundation for Medical Care of Kern & Santa Barbara Counties and HealthEdge Administrators is an Equal Opportunity Employer.

Job Type: Full-time

Pay: $64,875.00 - $85,592.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Travel reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Experience:

• Medical Plan Building: 5 years (Preferred)
• Medical Claims Processing: 5 years (Preferred)
• Health Insurance Industry: 5 years (Preferred)

License/Certification:

• Certified Professional Coder (Preferred)
• Certified Coding Specialist (Preferred)

Ability to Commute:

• Bakersfield, CA 93309 (Required)

Ability to Relocate:

• Bakersfield, CA 93309: Relocate before starting work (Preferred)

Work Location: In person

Salary : $64,875 - $85,592