Premium Analyst (Manager Care)

Novacore•Conshohocken, PA

About The Position

The Managed Care Premium Analyst plays a pivotal role in the administration and management of premium billing functions within the Managed Care program at Carbon Stop Loss Solutions. This position is responsible for ensuring accurate and timely billing for managed care products including HMO, PPO, EPO, and self-funded health plan arrangements, resolving complex billing issues, collaborating with underwriting, claims, network management, and accounting teams, and providing exceptional service to clients and carrier partners. The ideal candidate will have a strong background in managed care premium billing and health plan administration, excellent analytical skills, and the ability to manage multiple priorities while working independently.

Requirements

Bachelor’s degree in Business Administration, Finance, Accounting, Healthcare Administration, or a related field preferred.
Minimum of 5+ years of experience in premium billing within the health insurance or managed care industry.
Demonstrated experience with managed care products including HMO, PPO, EPO, and CDHP plans; experience with self-funded and level-funded arrangements strongly preferred.
Experience working with an MGU, TPA, health plan carrier, or employee benefits brokerage/consulting firm preferred.
Strong experience with billing systems, benefits administration platforms, and accounting software. Experience with ESL Office, BenAdmin, or similar group health billing systems preferred.
Strong attention to detail and accuracy in high-volume, multi-plan billing environments.
Familiarity with managed care concepts including network tiering, utilization management, care coordination, medical management programs, and their impact on premium structures.
Knowledge of ACA compliance requirements, ERISA, HIPAA, COBRA, and state-specific group health insurance regulations.
Excellent organizational and time management skills with the ability to manage multiple group accounts, billing cycles, and carrier relationships simultaneously.
Strong communication skills, both written and verbal, with the ability to explain complex billing and managed care concepts to employer groups, brokers, and internal stakeholders.
Proficient in Microsoft Office Suite, particularly Excel (including pivot tables and VLOOKUP for enrollment and billing reconciliation); experience with data imports/exports between billing and enrollment systems preferred.
Ability to work under pressure and meet tight billing deadlines while maintaining accuracy across a multi-carrier, multi-product managed care book of business.

Responsibilities

Oversee and process monthly premium billings for managed care products (HMO, PPO, EPO, CDHP) and self-funded health plan arrangements, ensuring accuracy and timeliness.
Review and analyze complex premium data, including composite and age-banded rating structures, adjusting for enrollment changes, plan design amendments, carrier rate changes, and mid-year renewals.
Administer premium remittance to carrier partners and reinsurers, ensuring proper allocation across multiple funding arrangements (fully insured, level-funded, and self-funded).
Collaborate with internal teams and outsourced partners to ensure premiums are billed accurately based on current enrollment data, benefit plan details, and carrier contract terms.
Process and validate member enrollment and eligibility data received from employer groups, ensuring accurate subscriber and dependent counts are reflected in monthly billings.
Manage retroactive enrollment adjustments and retroactive terminations, calculating and applying premium credits or back-billings as appropriate.
Coordinate with carrier partners to confirm eligibility file transmissions and resolve discrepancies between internal records and carrier enrollment rosters.
Serve as the primary point of contact for employer groups and brokers regarding premium billing inquiries, enrollment discrepancies, and payment issues specific to managed care products.
Provide clear, timely, and professional communication regarding billing statements, premium adjustments, payment schedules, and grace period policies in accordance with managed care contract terms.
Assist clients in understanding billing statements, rate structures, dependent tier categories, and payment schedules across multiple managed care plans offered under their group contracts.
Perform reconciliation of premium payments against carrier invoices and internal billing records, including matching payments, identifying discrepancies across multiple plan options, and resolving outstanding balances.
Prepare management reports highlighting billing trends, enrollment fluctuations, payment status, loss ratio indicators, and any potential issues affecting the managed care book of business.
Issue and manage delinquency notices in accordance with carrier contract requirements and applicable state continuation of coverage (COBRA/state continuation) regulations.
Track and report on experience refunds, dividend calculations, and carrier settlement reconciliations applicable to experience-rated managed care programs.
Recommend and implement process improvements to enhance billing accuracy, enrollment data integrity, and client satisfaction across the managed care program portfolio.
Ensure compliance with all applicable regulatory requirements including ACA mandates, ERISA, HIPAA privacy standards, and state insurance department regulations governing premium billing and group health coverage.
Assist in internal and external audits, ensuring that all billing records, enrollment files, and carrier remittance documentation are accurately maintained and readily available for review.
Maintain strong working relationships with carrier billing contacts to facilitate timely resolution of premium discrepancies, enrollment file errors, and remittance reconciliation issues.
Liaise with underwriting, network management, and claims teams to ensure premium rates accurately reflect negotiated network access fees, stop loss attachment points, and any applicable medical management program charges.
Work closely with underwriting, claims, network management, and policy issuance teams to ensure premiums are billed correctly and reflect current plan designs, negotiated rates, and carrier contract terms.
Assist in the training and mentorship of junior billing staff, providing guidance on complex managed care billing scenarios including multi-carrier arrangements and tiered network products.
Investigate and resolve billing discrepancies and client disputes related to premiums, enrollment counts, rate tier classifications, or carrier remittance errors across managed care products.
Escalate complex issues to management as needed while proposing effective solutions, particularly for situations involving carrier coverage disputes, retroactive rate changes, or lapse and reinstatement scenarios.