• Claims Plan Builder

    Job Locations US-IL-Aurora
    Posted Date 2 months ago(2/28/2019 5:24 PM)
    # of Openings
    Medical Claims
  • Overview




    Looking for a way to influence the health and healthcare of many?


    If so, we’d love to hear from you! Our mission-driven organization is focused on theTriple Aim - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans.


    UNITE HERE HEALTH serves 100,000+ workers and 220,000 covered lives in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!



    Key Attributes:


    • Integrity – Must be trustworthy and principled when faced with complex situations
    • Ability to build positive work relationships – Mutual trust and respect will be essential to the collaborative relationships required
    • Communication – Ability to generate concise, compelling, objective and data-driven reports
    • Teamwork – Working well with others is required in the Fund’s collaborative environment
    • Diversity – Must be capable of working in a culturally diverse environment
    • Continuous Learning – Must be open to learning and skill development.  As the Fund’s needs evolve, must be proactive about developing new areas of expertise
    • Lives our values – Must be a role model for the Fund’s BETTER Culture and Mission (Better, Engage, Teamwork, Trust, Empower, Respect)


    The purpose of this position is to support the Claims department by building medical, dental, disability and vision plans in the claim processing system. This position will evaluate the effectiveness of how the claims processing system is being utilized by the department with a focus on maximizing the capabilities of the system, by creating plan logics with an emphasis on accuracy and proficiency and solving system related issues.  This position will be responsible for representing the Critical Response Team as a subject matter expert and providing guidance and suggestions on process improvements to the Claims Department Leadership Team.


    Essential Job Functions:



    • Evaluates system potential and performance through feature and function testing
    • Maintains design specifications and testing through documentation and revisions
    • Researches system documentation for the purposes of implementing new features and/or better process design
    • Identifies system defects or errors and provides documentation
    • Evaluates and provides feedback on plan and benefit design
    • Consults with subject matter experts to accurately capture business requirements related to desired system function
    • Acts as the claims system functional expert, providing direct human interface with all aspects of the claims adjudication software
    • Acts as the liaison between the claim system vendor, the Operations Department and the claim system consultant for problems reported by users
    • Maintains a log of all significant problems, their impact on claim operations and their resolution
    • Coordinates and performs system loads and updates, including software, fee schedule, provider and all Fair Health/MDR loads
    • Researches plan provisions contained in benefit plan documents; clarifies ambiguities contained in the plan language and provisions
    • Converts plan provisions to claim system adjudication functions via claim system plan building interface
    • Utilizes benefit and system expertise to construct/build benefit plans and related tables within the claim system
    • Coordinates the development of solutions for system related issues that may prevent the use of automated or standard processing methods
    • Assists in developing test plans, arranging, coordinating and documenting system test cases
    • Provides timely documentation to users to help them reference, understand and implement system and/or plan changes
    • Updates the claim system to ensure claims are processed in accordance with plan changes
    • Maintains the claim system Plan Building mailbox to research and resolve system issues
    • Acts as a resource for management regarding the operations and capabilities of the claim system
    • Trains staff members on system changes/updates
    • Set goals and achieve measurable results
    • Contributes ideas to plans and achieving department goals
    • Performs other duties as assigned within the scope of responsibilities and requirements of the job
    • Performs Essential Job Functions and Duties with or without reasonable accommodation


    • High School Diploma or GED
    • College coursework preferred
    • 2 ~ 3 years of related experience minimum
    • Experience with Javelina claim adjudication system required

    • Knowledge and experience in medical, dental, vision, life, and LOT Claims required
    • Knowledge of major medical benefit application and plan building features required
    • Knowledge and experience in medical terminology including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD)-9 10 required
    • Experience in plan building and claim testing preferred



    Skills and Abilities:

    • Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook)
    • Intermediate level Microsoft Excel skills
    • Problem solving, multi-tasking, analytical, and decision making skills
    • Attention to detail, time management, organizational, and investigative skills
    • Excellent written and oral communication skills

    • Abilityto communicate system functions and requirements to developers, vendors abd business users

    • Strong interpersonal skills


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