Job Details

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.

Job Summary

Our client is seeking a highly skilled Health Plan Representative to serve as a subject matter expert (SME) and provide specializedsupport for health plan coding. The role involves conducting rigorous reviews, validation of health plan coding for accuracy, and strategic client implementations focusing on complex benefit structures.

Responsibilities / Job Duties

• Conduct rigorous review and validation of health plan coding for accuracy, consistency, and alignment with client-specific benefit designs and regulatory standards (e.g., ERISA, ACA).
• Translate complex Summary Plan Descriptions (SPDs) and Evidence of Coverage (EOC) into accurate, consistent, and compliant coding configurations within the benefit platform.
• Participate directly in coding the claim adjudication system.
• Conduct proactive and scheduled audits of coded benefits to ensure completeness and proper application across platforms.
• Provide coding expertise and guidance on edge cases and highly complex benefit structures to internal stakeholders (e.g., Member Claims, Care Navigation) to resolve processing issues.
• Lead the cross-functional process with the MCA team to track updates to benefit builds.
• Support continuous improvement efforts by identifying and recommending specific areas of coding optimization and enhancements.
• Communicate and educate internal departments on upcoming and impactful coding updates as required by project needs.

Minimum Education and Experience Qualification Requirements

Education

• Must hold an active coding credential from a recognized national organization (e.g., AAPC, AHIMA).

Qualifications

• 3+ years of direct, hands-on experience in a Third-Party Administrator (TPA) or Payer setting focusing on health plan coding, benefit configuration, or claims system setup.
• 1+ years of dental/vision insurance coding experience.
• Proven ability to navigate and interpret complex plan documentation and strong analytical experience working in enterprise benefit platforms (e.g., Facets, QNXT, HealthRules, or similar TPA/Payer systems).
• Expertise in translating complex benefit logic into code and performing root cause analysis on processing errors.

Schedule / Shift

• Business hours, M-F.
• Must reside in Central, Mountain, or Pacific time zones.

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.

* As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients