Health Plan Operations Specialist

Jefferson Health Plans • Philadelphia, PA

1d

About The Position

As a member of the Enterprise Office of Legal Affairs (EOLA), works with EOLA attorneys to ensure the efficient and effective provision of legal services to the Thomas Jefferson University and Jefferson Health Plans community, including each HMO and licensed insurer comprising Jefferson Health Plans and their associated departments, divisions and business units, in connection with health plan operations and associated contracts, transactions, regulatory matters, and operational issues, across a variety of legal practice areas. Manages administration of internal appeals processes and administrative hearings, including all aspects of internal appeals processes, scheduling, assisting in preparation of administrative hearings, attendance and representation of the health plan at administrative hearings, when directed by supervising attorney (and opposing party is not represented by counsel), all aspects of internal appeals processes, and appropriate documentation of such appeals processes. Manages regulatory reporting obligations and coordinates with responsible business units to gather and prepare such reports and filings in accordance with all regulatory requirements. Conducts primary review of selected health plan operations-related contracts and supports EOLA evaluation and response to other health plan operations-related legal issues. Coordinates contract template development initiatives for health plan operations in collaboration with EOLA attorneys. Position will directly and independently interface extensively with business persons, executives and regulatory authorities. Supports management of EOLA’s role in complaints, grievances, and appeals for Jefferson Health Plans. Manages administration of internal appeals processes and administrative hearings, including all aspects of internal appeals processes, scheduling, assisting in preparation of administrative hearings, attendance and representation of the health plan at administrative hearings, when directed by supervising attorney (and opposing party is not represented by counsel), all aspects of internal appeals processes, and appropriate documentation of such appeals processes Manages receipt, review and response to beneficiary records requests, subpoenas and court orders for records requests. Manages regulatory reporting obligations and coordinates with responsible business units to gather and prepare such reports and filings in accordance with all regulatory requirements and with respect to general corporate matters. Supports management of EOLA’s role in policy development, review and approval for Jefferson Health Plans. Supports EOLA’s evaluation and response to other health plan operations-related legal issues. Coordinates contract template development initiatives for health plan operations in collaboration with EOLA attorneys. Reviews and analyzes various agreements to determine contractual obligations upon request from attorneys or other departments and, if necessary, escalates unresolved issues and disputes to attorneys. Reviews, drafts, redlines and negotiates selected health plan-oriented contracts, agreements, amendments and other legal documents. Consults with EOLA colleagues relative to enterprise and departmental business operations. Conducts legal research as requested. Supports adoption and administration of Jefferson’s enterprise-wide contract management platform. Independently cultivates and manages client relationships with Jefferson stakeholders and business relationships with external parties. Participates and attends relevant committees and meetings at Jefferson locations, as instructed. Supports the legal, compliance and risk teams on other matters as needed. Interacts with co-workers, visitors and other staff consistent with the values of Jefferson. Performs other tasks, as assigned by EOLA.

Requirements

• Bachelor’s Degree
• 5 years of law firm, in-house legal department experience and/or in-house health plan experience
• Ability to act independently and experience in managing annual reporting requirements for health plan entities regulated by state insurance departments, as well as experience in managing complaints, grievances and appeals of health plan members and/or providers, including administrative law hearings.
• Proficient in Microsoft Word, Microsoft Excel, Microsoft PowerPoint and various database and document management systems.

Nice To Haves

• Experience reviewing, negotiating and drafting a myriad of agreements preferred.
• Background in health plan and regulated insurance industry preferred.

Responsibilities

• Supports management of EOLA’s role in complaints, grievances, and appeals for Jefferson Health Plans.
• Manages administration of internal appeals processes and administrative hearings, including all aspects of internal appeals processes, scheduling, assisting in preparation of administrative hearings, attendance and representation of the health plan at administrative hearings, when directed by supervising attorney (and opposing party is not represented by counsel), all aspects of internal appeals processes, and appropriate documentation of such appeals processes
• Manages receipt, review and response to beneficiary records requests, subpoenas and court orders for records requests.
• Manages regulatory reporting obligations and coordinates with responsible business units to gather and prepare such reports and filings in accordance with all regulatory requirements and with respect to general corporate matters.
• Supports management of EOLA’s role in policy development, review and approval for Jefferson Health Plans.
• Supports EOLA’s evaluation and response to other health plan operations-related legal issues.
• Coordinates contract template development initiatives for health plan operations in collaboration with EOLA attorneys.
• Reviews and analyzes various agreements to determine contractual obligations upon request from attorneys or other departments and, if necessary, escalates unresolved issues and disputes to attorneys.
• Reviews, drafts, redlines and negotiates selected health plan-oriented contracts, agreements, amendments and other legal documents.
• Consults with EOLA colleagues relative to enterprise and departmental business operations.
• Conducts legal research as requested.
• Supports adoption and administration of Jefferson’s enterprise-wide contract management platform.
• Independently cultivates and manages client relationships with Jefferson stakeholders and business relationships with external parties.
• Participates and attends relevant committees and meetings at Jefferson locations, as instructed.
• Supports the legal, compliance and risk teams on other matters as needed.
• Interacts with co-workers, visitors and other staff consistent with the values of Jefferson.
• Performs other tasks, as assigned by EOLA.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level