Health Care Contract Specialist

Health Care Contract Specialist needed in Rockville, MD - WE WANT TO TALK TO YOU!

As a global business and technology consulting services leader, Enclipse focuses on delivering tangible solutions.

By employing a team committed to questioning and challenging the status quo, Enclipse has established a culture that encourages independent thought, innovation, and flexibility.

If you join Enclipse, you can expand your technology platform while working for the Nation's most dynamic Health Care Leader.

We Provide:

Class A Benefits that Start ASAP

The Personal Touch -- You deserve it, We deliver it!

Contract Terms: W2

Rockville, MD 20852

10months +

Health Care Contracts Specialist

Job Summary

- To support contractual leadership and expertise to the contract administration department by taking responsibility for the coordination, implementation and administration of the Region's contracts and benefits which include:
- Participating in cross-functional work efforts related to the clarification, interpretation, benefit administration, pricing activities and medical policy development and
- Creating written materials used to communicate with regulators and internal stakeholders.

Major Responsibilities/Essential Functions

- Is responsible for on-going development and administration of Health Plan membership contracts and related documentation for an assigned product segment.
- Develops filing strategies and secures regulatory approval with the appropriate Departments of Insurance. Monitors and tracks progress to approval. Maintains positive working relationship with regulators
- Ensures the accuracy and compliance of all regulatory filings related to the assigned product segment.
- Is responsible for ensuring the issuance of all the Health Plan's group, non-group, and ancillary benefit plans, contracts, forms and evidence of coverage (for both new products and existing products) in accordance to regulatory statues, lines of business and timelines.
- Oversees the on-going administration of the region's Federal contract with the Office of Personnel Management including the annual benefit submission and on-going reports. Maintains relationship with OPM on a local level.
- Oversees the implementation, development and on-going administration of the region's Medicaid contracts related to member handbook requirements (including the annual benefit submission and on-going reports).
- Is responsible for developing and implementing policies and guidelines related to benefit and contractual interpretation with the Medical Group and Regional Administration.
- Serves as the primary resource for resolution of benefit and contractual clarification issues. Familiar with ICD 9, CPT and other benefit classification/coding tools to ensure appropriate medical definition and benefit rules.
- Provides strategic input into the benefit designs for products such as POS, OOA, Medicare, Self funding, Medicaid etc. to expedite regulatory filing and approval cycle.
- Collaborates with department responsible for configuration of systems to reflect accurate benefit information.
- Manages all functions related to the filing, and member contractual issuance for the assigned product segment.
- Manages and implements Federal and State regulatory requirements and laws as they relate to Health Plan benefits and contracts to assure compliance in all jurisdictions.
- Identifies and articulates problems and formulates responses without precedents.
- Is responsible for analysis, communication and dissemination of information on benefits and contracts of the assigned product segment and establishing guidelines for administration of such within the Region for both administrative and medical group managers.

Job Qualifications

Minimum Education

- BS/BA in marketing, healthcare, or related field required or equivalent (four) years of experience working in a Managed Care environment is required.

Preferred Education

- Master's Degree in liberal arts, healthcare or related field preferred.
- Minimum Work Experience and Qualifications
- Five years of experience in progressively responsible positions
- Two years of experience in regulatory/legal related activity required.

Other Minimum Requirements

- Working knowledge of Federal HMO Laws OPM/FEHB Regulations; State laws such as Maryland & Virginia HMO Laws Federal TEFRA, COBRA, Medicare and Medicaid Laws and Maryland COBRA Laws & Regulations is required.
- Excellent written and oral communications skills required.
- Demonstrated ability to effectively use PC and/or Mainframe computers required.
- Knowledge of current health care marketplace dynamics and client's position in the market required.
- Knowledge of health insurance products, rating methodologies, and strategies required.

Preferred Work Experience and Qualifications

- Health care, benefits, and/or insurance experience preferred.
- Knowledge of medical terminology, benefit coding, and clinical procedures preferred.
- Experience and knowledge of benefit, MCO or provider contracts preferred.
- Knowledge of project management, spreadsheets, presentation graphics, and word processing preferred.