Corporate Administrator, Employee Health Plan in Ontario, CA at Prime Healthcare

Date Posted: 7/26/2019

Job Snapshot

  • Employee Type:
  • Location:
    3300 East Guasti Road
    Ontario, CA
  • Job Type:
  • Experience:
    At least 3 year(s)
  • Date Posted:

Job Description


The Corporate Administrator of Benefits is responsible for the development of staff, processes and systems to effectively operate all aspects of the Prime Corporate Benefits Plans including the Self-Insured Health Plans.  This includes oversight of a comprehensive Utilization Review process of the self-insured employee medical plan, according to the EPO Plan Documents and any other applicable documents. Provides leadership and direct supervision to Utilization Review, Claims, Customer Service, Benefits and its employees. Provides oversight of processes, technology and performance to achieve Benefits goals.  Provides inter-professional collaboration with hospital and facility-based teams, including case managers, benefit coordinators and discharge planners.  Assesses needs and plans, communicates and designs services and strategies to forward the mission and serve member needs. Develops comprehensive Policies and Procedures for guidance and instruction of the UM Department, Claims, Customer Service and Benefits. Tracks and reports frequently to VP of Employee Health on department and individual team productivity. Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Present on site at Corporate Office full time. Works with the Utilization Review Manager to provide guidance on complex Authorizations, Referrals, Denials and Appeals. If appropriate clinical background, reviews all medical cases prior to escalating to VP of Employee Health or CMOs. Works with the VP of Employee Health and appropriate Directors and Managers of the Department to develop and implement new processes arising out of the new agreements with a Tier 2 Health Plan and the TPA. Ensures that TPA and Health Plan are notified in a timely fashion of any changes in process or procedures which would impact their functions.  Implements processes to improve administration of benefits, utilization review, member services, health plan network development, claims review and audits, coordination between all areas of the Benefits Department and its members to forward the goals of value and quality care. #LI-CC1


Required qualifications:

  • A minimum of 5 years’ experience as an Administrator of a Health Plan, a large IPA, or a complex Medical Group.

  • MBA or equivalent degree

  • Knowledge of Milliman Care Guidelines, Inter Qual Criteria and CMS Criteria

  • Knowledge of self-funded plans, ERISA and HIPPA guidelines

  • Experience and knowledge of intermediate computer skills e.g. Microsoft Suite

  • Knowledge of Medical Claims review and audit process

  • Clinical and financial skills to manage a self administered Health Plan for 46,000 members

  • Excellent interpersonal and communication skills including ability to prepare and give presentations to Hospital C-Suite electronically and in person.

  • Ability to develop complex communications including Policies, Procedures, detailed memos and other correspondence.

  • Preferred qualifications:

  • Minimum 3 years' experience as Administrator of a Self-Insured Health Plan.

  • RN degree minimum BSN with active California RN License and seven years post graduate.

  • Certification in Case management.

  • Knowledge of Customer Service process and Call Center.

  • We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: