Plan Design Analyst

            JOB DESCRIPTION

 

 

Job Title:  Level II PLAN DESIGN ANALYST

 

SUMMARY:

 

Specializes in claims processing system functionality.  Maintains and coordinates benefit plan set up and maintenance. Assists in point of sales issues, pharmacy networking and implementations.

 

ESSENTIAL FUNCTIONS:

 

· Work with Client Services to implement new and maintain existing plans in the claims processing system based on Benefit Design Summary or plan change order. 

 

· Work with Clinical Services to implement formulary updates and clinical programs in the claims processing system.

 

· Work with Provider Relations to implement pharmacy rate changes and network additions.

 

· Perform Testing and review of new and changed Plan set-up.

 

· Maintain acceptable and appropriate quality and production levels commensurate with job experience.

 

· Assist with inquiries from Client Services, Clinical Services, and Help Desk on the processing system functionality.

 

· Review and provide resolution to processing issues referenced by the help desk.

 

· Communicate training issues vs. programming issues to help desk supervisors.

 

· Opening the TCT window for pharmacy back billing.

 

· Exhibiting compliant and ethical behavior in the performance of job responsibilities, including complying with all applicable federal and state laws and regulations, HealthExtras Code of Conduct, Business Ethics Policies and Procedures and other polices and procedures applicable to position.

 

· Actively participating in HealthExtras’ Compliance and Ethics Program, including attending annual compliance and ethics training and reporting suspected violations of the law or HealthExtras polices and procedures via HealthExtras Procedures for Reporting Incidents of Possible Improper Employment Practices, Misconduct, or Improper Financial/Accounting Practices.  

 

· Other duties as assigned to assist in meeting department and corporate goals and objectives. i.e. special projects.

 

QUALIFICATIONS:

 

Requires a Bachelor’s Degree and 3+ years experience or an equivalent combination of education and experience.  Prefer  1 year RxClaim experience.  Must have Microsoft proficiency, and possess strong communication, problem-solving, and organizational skills.  Healthcare experience is highly preferred, as is clinical/PBM experience.