Benefit Guide

Overview

Now is the time to join us! 

At Virgin Pulse we value and celebrate diversity and we are committed to creating an inclusive environment for all employees. We believe in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce better solutions. But more than this, diversity is our strength, and a catalyst in our ability to #changelivesforgood.   

Responsibilities

Who are you?

The Benefit Guide will support members who are having difficulties utilizing their available benefits or issues related to claims incurred as a result of using their benefits. 

In this role you will wear many hats, but your knowledge will be essential in the following:  

• Support members in interpreting and understanding their medical billing and claims.
• Advocate for the member to receive coverage for the appropriate medical procedures, medications, and inpatient/outpatient treatment.
• Establish and maintain a network of key contacts within insurance carriers, federal and state offices, and the health insurance industry.
• Assist in resolving unpaid claims when necessary.
• Assist members in appealing denied claims verbally or in writing when appropriate, including preparing the member for oral appeals hearings.
• Serve as subject matter expert in the interpretation of health insurance plan language and state and federal regulation.
• Negotiate fees on behalf of the member including facilitating communication between the member and the billing agent.
• Research denied claims and verified proper coding.
• Provide education to members on their insurance plan provisions.
• Assist internal staff in complicated claims related cases.
• Document all cases in case system using following department documentation standards.
• Provide added value to our services by going beyond the member’s initial request.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Qualifications

What you bring to the Virgin Pulse team

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

• Five or more years of experience in health benefits or health insurance appeals preferred.
• Experience in reviewing, interpreting, and researching Explanation of Benefits (EOB’s) and denial letters.
• Experience in identifying contractual appeal timeframes.
• Familiarity with benefit plan documents, certificates of coverage, and benefit contracts, and plan riders
• Understanding of insurance carrier claims processing
• Knowledge of Durable Medical Equipment (DME) prescription procedures and plan riders
• Strong desire to provide outstanding customer service.
• Ability to work as part of a team.
• Ability to educate callers.
• Strong listening skills and empathy
• Ability to ask open-ended questions and uncover information.
• Effective communication skills to interact with members, physicians, and insurance carrier representatives.
• Special ability in mediating or negotiating compromises without alienating any party.
• Ability to calm anxious callers and defusing angry or hostile callers.
• Assertive, self-confident, and resilient
• Attention to detail and strong documentation skills.
• Proficient computer skills (Microsoft Office, Excel, Outlook, Adobe PDF, Internet Searches).

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• Understanding of health plan authorizations, including medical policy and claims payment guidelines to evaluate if appeals require clinical or administrative review.
• Knowledge of applicable law and resources regarding confidentiality of privileged patient information and appeals administration.
• Knowledge of procedure and diagnosis coding (ICD-9, HCPCS, and CPT-4)
• Familiarity with various types of health insurance coverage, coordination of benefits, and UCR fees

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you!

Why work at Virgin Pulse?   

We believe a career should provide competitive pay and benefits, a collaborative and supportive culture and cutting-edge technology and services. Virgin Pulse is an equal opportunity organization and is committed to diversity, inclusion, equity and social justice. To that end, we make a particular effort to recruit candidates from minoritized backgrounds to apply for open positions.

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges up to $57,000 annually. Note that salary may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits.

Salary : $57,000