****TO APPLY FOR THIS POSITION, PLEASE CLICK ON THE LINK BELOW:
http://www.cowcreek-nsn.gov/employment/
Benefits Administration Manager
Job Code: 1131
Department: Benefits Administration
Location: Roseburg, OR
Minimum Salary $67,358.46 DOE
POSITION SUMMARY:
This position is responsible for overseeing the day-to-day administration and operations for Cow Creek Band of Umpqua Tribe of Indians health plan, Nesika Health that is self-fund and self-administered for employees and Tribal Members. This position ensures that member eligibility, enrollment, claims processing, benefit determinations, appeals, customer service, vendor coordination, financial controls, and regulatory requirements are managed accurately, efficiently, and consistently with the governing plan documents. This position works closely with Director of Benefits to assist with Risk Management, stop loss tracking and reporting, and Purchase and Referred Care (PRC) Tribal programs.
This position provides leadership, guidance and training to administration staff, monitors operational performance and is responsible for identifying opportunities to strengthen internal controls, improve member service, manage plan costs, and ensure the continued integrity of the health plan.
ESSENTIAL DUTIES and RESPONSIBILITIES:
• Manage the daily operations of self-funded, self-administered health plan and Tribal programs and provide support to Director of Benefits Administration and Risk Manager.
• Review complex or unusual benefit questions and offer recommendations regarding appropriate plan administration.
• Interpret plan provisions and provide guidance to staff, members, providers, and organizational leadership regarding coverage, exclusions, limitations, and administrative requirements.
• Promote responsive, respectful, and accurate service to members, dependents, providers, and organizational stakeholders.
• Oversee administration of appeals, grievances, benefit inquires and ensure adverse benefit determinations and appeal responses are accurate, timely, clearly written, and consistent with plan requirements.
• Establish and maintain quality assurance processes, including claim audits, accuracy reviews, and corrective action procedures.
• Coordinate claim corrections, overpayment recoveries, refunds, subrogation matters, third party liability activities, and work with stop loss to identify, document, submit, and reconcile eligible reimbursement claims.
• Develop clear member communications regarding eligibility, benefits, claims, plan changes, ID cards, open enrollment, and other health plan matters.
• Identify training needs and develop education related to plan provisions, claims processing, privacy requirements, customer service, and administrative procedures.
• Ensure claim payments and administrative expenses are properly authorized, recorded, and reconciled. Assist with annual budgeting, forecasting, reserve analysis, plan projections, and renewal planning.
• Support compliance with HIPAA, ACA, COBRA, ERISA, mental health parity requirements, claims and appeals rules, and other requirements as applicable to the plans and programs.
QUALIFICATIONS:
• Associates Degree or greater in related field.
• Five years experience in employee benefits, health plan administration, healthcare claims, insurance operations, or related field.
• Two years of supervisory, lead, or management experience.
• Health and Life State License (if not current, may be completed within 6 months of hire).
• Knowledge of provider billing, medical coding, utilization management, coordination of benefits, subrogation and third-party liability.
• Proficiency with claims administration systems, eligibility systems, Office 365 applications, and reporting tools.
• Strong analytical and problem-solving skills, including the ability to identify discrepancies, trends, operational risks, and cost drivers.
• Knowledge of medical and prescription benefit terminology, claims processing practices and eligibility administration.
• Current and valid Oregon Driver’s License with the ability to qualify for the Cow Creek Government Office Drivers Program.
****TO APPLY FOR THIS POSITION, PLEASE CLICK ON THE LINK BELOW:
http://www.cowcreek-nsn.gov/employment/
