About the position
We are recruiting for a motivated Health Plan Representative - Denver Health Medical Plan (*Colorado State Applicants Only*) to join our team! We are here for life’s journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. Under general supervision, assists with the day-to-day operations of the Denver Health Medical Plan. Identifies, researches, and resolves complex problems by assisting members and providers in resolving their health plan related issues. Effectively makes decisions regarding whether member or provider information meets requirements for programs when circumstances require exceptions from, or interpretations of, rules, regulations or policies. Follows escalation procedures, and assists with documenting and tracking appeals and grievances. Collaborates directly with both internal and external partners such as State entities, other departments and community organizations.
Responsibilities
- Identifies, researches, and resolves complex problems related to health insurance benefits, eligibility, utilization, authorizations and claims by assisting members and providers in resolving their issues.
- Communicates and explains health plan benefits, EOBs, RAs and claims data.
- Actively identifies programmatic and technical (system) issues and recommends and implements solutions to those challenges.
- Receives, processes and verifies health premium payments.
- Identifies appropriate solutions and involves others in the implementation process.
- Communicates member and provider communication trends and recommendations with department leadership.
- Effectively makes decisions regarding whether member or provider information meets requirements for programs when circumstances require exceptions from, or interpretations of, rules, regulations or policies.
- Follows escalation procedures, and assists with documenting and tracking member and provider appeals and grievances.
- Collaborates directly with both internal and external partners such as State entities, other departments and community organizations.
- Collects data utilizing various tracking tools that have been developed to monitor performance.
Requirements
- High School Diploma or GED required.
- 1-3 years Health Plan or customer service experience required.
- Knowledge of health care administration, including managed care, Medicaid, Medicare, Exchange and CHP+ eligibility and enrollment policies and processes.
- Knowledge of federal and Colorado statutes, legislative initiatives and regulations, as well as federal, state and local policies.
- Skilled in analytical thinking, problem solving, and process improvement.
- Skills in providing excellent customer service.
- Ability to communicate effectively.
- Ability to disseminate program information, policies, rules and/or regulations.
- Ability to simultaneously coordinate and manage several functions, programs, and projects in various stages of completion.
- Ability to consistently implement program, department and organizational policies and procedures.
- Ability to work in teams to get projects done, and to work with those at all levels of the organization.
- Knowledge of PC applications, specifically Microsoft Office products, and the ability to learn new computer applications.
- Knowledge of health plan information systems, preferably QNXT and MMIS.
Benefits
- Outstanding benefits including up to 27 paid days off per year.
- Immediate retirement plan employer contribution up to 9.5%.
- Generous medical plans.
- Free RTD EcoPass (public transportation).
- On-site employee fitness center and wellness classes.
- Childcare discount programs & exclusive perks on large brands, travel, and more.
- Tuition reimbursement & assistance.
- Education & development opportunities including career pathways and coaching.
- Professional clinical advancement program & shared governance.
- Public Service Loan Forgiveness (PSLF) eligible employer + free student loan coaching and assistance navigating the PSLF program.
- National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer.
