Health Plan Operations Specialist

Job Details

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.

Job Description

• Supports management of EOLAs 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 EOLAs role in policy development review and approval for Jefferson Health Plans.
• Supports EOLAs 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 Jeffersons 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.

Education and Experience:

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

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University

Primary Location Address

1101 Market Philadelphia Pennsylvania United States of America

Nationally ranked Jefferson which is principally located in the greater Philadelphia region Lehigh Valley and Northeastern Pennsylvania and southern New Jersey is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65000 people strong dedicated to providing the highest-quality compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrows professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic clinical and applied research. Thomas Jefferson University home of Sidney Kimmel Medical College Jefferson College of Nursing and the Kanbar College of Design Engineering and Commerce dates back to 1824 and today comprises 10 colleges and three schools offering 200 undergraduate and graduate programs to more than 8300 students. Jefferson Health nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age race color religion creed sexual orientation gender gender identity marital status pregnancy national origin ancestry citizenship military status veteran status handicap or disability or any other protected group or status.

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 diemcolleagues adjunct faculty and Jeff Temps) have access to medical (including prescription) insurance.

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