Health Plan Representative - Denver Health Medical Plan *Colorado State Applicants Only*

$48,152 - $65,146/Yr

Denver Health

Full-time - Entry Level

Remote

Hospitals

About the position

The Health Plan Representative at Denver Health Medical Plan plays a crucial role in assisting with the day-to-day operations of the health plan. This position involves identifying, researching, and resolving complex health plan-related issues for members and providers, ensuring effective communication and collaboration with various stakeholders. The representative is responsible for making informed decisions regarding program requirements and handling appeals and grievances, all while providing excellent customer service and support to the community.

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.