Job Details

Who we are

Community Health Plan of Washington is
an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or otherunlawful consideration.

Our commitment is to:

• Strive to apply an equity
lens to all our work.

• Reduce health disparities.

• Become an anti-racist organization

• Create an equitable
work environment.

** This role is remote in Washington State only**

About the Role

Responsible for sustaining processes and executing process improvement and quality monitoring within Claims Operations and the business processes impacted by Operations data and systems.

This position is temporary, employment will end when project funding concludes.

To be successful in this role, you:

• Bachelor's degree in health care or related field or an equivalent combination of education and highly relevant experience required.
• Minimum three (3) years' managed care/health plan operations experience required, with proven broad knowledge and execution of quality improvement methods and tools.
• Minimum two (2) years' business/operations analysis experience in a related field required.
• Background in Medicaid and Medicare claims adjudication, benefits configuration, claims coding, electronic data interface, and encounter data reporting preferred.
• Experience in managed care/health plan operations and business/operations analysis experience in a related field.

Essential functions and Roles and Responsibilities:

• Responsible for State and CMS claims benefit interpretation and application, and oversight of system benefit and pricing configuration.
• Gather business requirements for claims benefit configuration to support system updates, enhancements and implementation of new products.
• Facilitate the development and execution of user acceptance scenarios and scripts for testing of system changes, implementations, and enhancements. Peer review and support system enhancements and configuration of vendor systems.
• Provide support for electronic data interchange (EDI) data files and CHPW web-based interfaces.
• Interpret, monitor, and ensure compliance with state, CMS, OIC requirements; pricing, audit performance, encounter data submissions/reporting, and vendor management.
• Other duties as assigned.

Knowledge, Skills, and Abilities:

• Knowledge of the healthcare industry, which includes claims adjudication, benefits configuration, claims coding, electronic data interface, and/or encounter data reporting.
• Knowledge of quality improvement methods and tools.
• Team facilitation skills.
• Project management Skills
• Communication skills, both verbal and written.
• Technical, analytical and process documentation skills
• Ability to multi-task, prioritize, work under pressure as well as work with other departments and people at all levels within the organization.
• Ability to gather and assess data, problem-solve, and consult/follow up with stakeholders.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant's criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime. Based on market data, this position grade is (65) and has a 10% annual incentive target based on company, department, and individual performance goals.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&D, Short and Long-Term Disability
• Voluntary Life, Critical Care, and Long-Term Care Insurance
• 401(k) Retirement and generous employer match effective the 1st of the month following or coinciding with the employee's start date
• Wellness programs (Employee Assistance Program and Mental Fitness app)
• Financial Coaching, Identity Theft Protection
• Paid Time Off (PTO) including PTO accrual starting at 17 days per year
• 40 hours Community Service volunteer time
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty
• A monthly stipend to offset work-from-home expenses for roles that are 100% remote

Sensory/Physical/Mental Requirements:

Sensory*:

Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking, and possibly standing.
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.

Mental:

Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

Work Environment:

• Office environment. Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.