What are the responsibilities and job description for the Plan Builder System Specialist position at TRISTAR RISK MANAGEMENT?
This position will be office-based, during the required training, which may last up to 6 months. Once training is complete, the position may become hybrid or 100% remote-based, subject to company remote-work policies. Working permanently on a remote or hybrid schedule is not a guarantee for this position.
POSITION SUMMARY: Under minimal supervision the Plan Builder/Systems Specialist is responsible for ensuring accurate and timely implementation and ongoing building of benefit plans into the Claims system. This individual serves as a credible and reliable source of reference to the organization regarding benefit plan building and design, to ensure timely and accurate benefit applications and processing.
DUTIES AND RESPONSIBILITIES:
- Implement Benefit Plans into Claims system through targeted building plan procedures in the industry.
- Revise benefit plan designs as needed to update adjudication of claims based on Client changes and ensure accurate execution and compliance with Client benefit programs.
- Conduct ongoing testing of new and existing contracts, plan builds, and rule updates.
- Build new and revise existing contracts/fee schedules for providers.
- Program and/or build interfaces to receive EDI imports and enable auto adjudication of claims where appropriate.
- Perform provider maintenance data entry, monitoring, and editing in system of provider profiles and demographics.
- Work collaborative with director of operations, IT team, claims adjusters, customer services, eligibility and auditing to ensure ongoing dialogue, correction, and resolution to system identified issues.
- Assist in identifying and troubleshooting issues outside of the scope of plan building and of high relevance to TBA operations and client satisfaction.
- Review and obtain approval of completed plan building of benefit program provisions.
- Facilitate meetings with the appropriate TBA department personnel to review new benefits, contracts and/or review system issues/concerns.
- Attach provider contracts and/or fee schedules to providers in system and conduct tests to ensure payment is in accordance to provider network contract provisions.
- Provide assistance to client base to resolve benefit plan design issues or requests for changes.
- Prioritize assignments to ensure timely implementation of benefit plans for claims adjudication.
- Handle daily operations related to running, printing and mailing system generated letters.
- Responsible for provider network authorizations into system and related operations.
- Responsible for building effective and client program appropriate system generated letters as applicable.
- Run CIL for all claims routed to Provider Maintenance, review, and build or correct as needed.
- Responsible for weekly check runs for all supported client benefit program payments.
- Serve as the back-up for the IT support as needed to load electronic claims into system.
- Stay up to date and in compliance with applicable, laws, rules, and regulations related to benefit programs and claims adjudication.
- Daily attendance and punctuality are essential requirements for this position.
- Perform other duties as assigned.
EQUIPMENT OPERATED/USED: Computer, 10-key, printer, copier, fax machine and other office equipment.
SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire required when conducting business with internal/external personnel remotely or in person.
QUALIFICATIONS REQUIRED:
Education/Experience:
Associates degree or higher education preferred. High School diploma plus work experience in a similar industry preferably as a claims supervisor or Plan Builder, or a combination of relevant skills and experience.
Other Qualifications:
- 3 years Managed Care/Health Plan experience in claims processing and/or member service capacity required.
- 3 years of experience interpreting benefit plan designs and summary plan descriptions required.
- Excellent and proficient knowledge of claims adjudication systems required.
- ICD-9/ICD-10, CPT coding, U&C coding, and medical terminology required.
- Proficient EDI import and auto adjudication experience required.
Knowledge, Skills and Abilities:
- Possess exceptionally strong written and verbal communication skills, including the ability to convey technical details.
- Innate ability to manage multiple projects concurrently and meet strict deadlines.
- Must be detail-oriented, analytical and a problem solver.
- Possess strong and effective organizational skills.
- Ability to work alone and in a team environment.
- Possess in-depth knowledge of plan building system operations.
- Intermediate to advance knowledge of Word, Excel, PowerPoint, Salesforce, and customer service technology.
- Possess and demonstrate effective entrepreneurial skills.
- Highly detail oriented, excellent problem solving skills, ability to consistently meet minimum production standards, and maintain a positive attitude towards colleagues and clients.
- Ability to establish and maintain a high level of client trust and confidence.
Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]
MENTAL AND PHYSICAL REQUIREMENTS
1. MENTAL EFFORT
a. Reasoning development::
Follow one- or two-step instructions; routine, repetitive task.
Carry out detail but uninvolved written or verbal instructions; deal with a few concrete
variables.
Follow written, verbal, or diagrammatic instructions; several concrete variables.
Solve practical problems; variety of variables with limited standardization; interpret instructions.
X Logical or scientific thinking to solve problems; several abstract and concrete variables.
X Wide range of intellectual and practical problems; comprehend most obscure concepts.
b. Mathematical development:
Simple additional and subtraction; copying figures, counting, and recording.
Add, subtract, multiply, and divide whole numbers.
X Arithmetic calculations involving fractions, decimals, and percentages.
Arithmetic, algebraic, and geometric calculations.
_X_ Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.
c. Language development:
X Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
X Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
X Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.
2. PHYSICAL EFFORT
a. Physical activity required to perform the job:
Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
X Light work:
a. Exerting up to 20 pounds of force occasionally
b. Exerting up to 10 pounds frequently
c. Exerting a negligible amount of force constantly to move objects
(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).
Medium work:
a. Exerting up to 50 pounds of force occasionally
b. Exerting up to 20 pounds of force frequently
c. Exerting up to 10 pounds of force constantly to move objects
Heavy work:
a. Exerting up to 100 pounds of force occasionally
b. Exerting up to 50 pounds of force frequently
c. Exerting up to 20 pounds of force constantly to move objects
Very heavy work:
a. Exerting in excess of 100 pounds of force occasionally
b. Exerting in excess of 50 pounds of force constantly to move objects
c. Exerting in excess of 20 pounds of force constantly to move objects
- Visual requirements necessary to perform the job:
Far vision: clarity of vision at 20 feet or more
X Near vision: clarity of vision at 20 inches or less
X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet
Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are
Color vision: ability to identify and distinguish colors
Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point
2. PHYSICAL EFFORT (cont.)
FREQUENCY
c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):
Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.
X Kneeling: Bending legs at knee to come to a rest on knee or knees.
X Crouching: Bending the body downward and forward by bending legs and spine.
Crawling: Moving about on hands and knees or hands and feet.
X Reaching: Extending hand(s) and arm(s) in any direction.
X Standing: Particularly for sustained periods of time.
X Walking: Moving about on foot to accomplish tasks, particularly for long distances.
X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.
X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.
Foot
Motion: Using feet to push pedals.
X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.
X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.
X Grasping: Applying pressure to an object with the fingers and palm.
Occasionally
Occasionally
Occasionally
Occasionally
Occasionally
Occasionally
Occasionally
Occasionally
Frequently
Frequently
Occasionally
2. PHYSICAL EFFORT (cont.)
FREQUENCY
X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts.
Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.
X Repetitive Substantial movements (motions) of the wrists, hands,
Motion: and/or fingers.
Frequently
Frequently
Frequently
3. WORKING CONDITIONS
Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.
WORKING CONDITION
ENVIRONMENTAL
FACTOR
NATURE/REASON
OF EXPOSURE
FREQUENCY
Dirt/Dust
Noise
Temperature extremes
Dampness
Vibrations
Equipment movement hazard
Chemicals/solvents
Electrical shock
Significant work pace/pressure
Odors/Fumes
Other (specify):