JOB SUMMARY: Incumbent will provide leadership and direction for claims administrative and support functions including application development and oversight, liaison between quality assurance and training, defect reduction initiatives and process improvements. Responsible for acquisition activity as it relates to claims due diligence and implementation. Responsible for planning, implementing and controlling the strategies and programs of the Claims Department that will ensure efficient operations, customer satisfaction and quality service with emphasis on defect reduction. Ensures business processes and results demonstrate adherence and compliance with federal/state/regulatory standards and procedures while meeting company goals and objectives.
PRIMARY RESPONSIBILITIES: 1.Interfaces with and builds internal and external relationships to ensure superior service. Works with business partners such as the Health Plans, Providers, and internal departments.
2.Manages, controls, directs and takes corrective action with specific strategies to ensure overall performance meets Federal, State and Regulatory requirements.
3.Evaluates the Claims Operations to develop and implement specific improvement programs to correct deficiencies in order to meet specific service standards.
4.Has responsibility for meeting all cost, quality and performance objectives that strengthen the companyís ability to manage SG&A expenses and supports the medical expense objectives to ensure the corporation meets its financial goals.
5.Supports the strategic planning process for the Claims Department that supports the overall mission and financial goals of the organization.
6.Manages and monitors departmental budget. Monitors and controls expenses by ensuring adequate departmental controls and prudent oversight of discretionary expenses.
7.Develops and implements new, more efficient or cost effective methods or those required by changes in the business environment as it relates to claims processing.
8.Key participant in activities related to corporate Mergers and Acquisitions to ensure successful transition of core business functions.
9.Responsible for compliance with all Sarbanes-Oxley controls/compliance. Responsible for process controls across multiple platforms.
10.Other duties as assigned or requested.
Education and Experience:
Required: Bachelorís Degree in Healthcare or Business Administration or equivalent experience may be substituted
Years and Type of Experience
Required: 10 years of management and planning experience with 4 years of Senior Management experience
Specific Technical Skills
Required: Broad knowledge of Claims Operations and Customer Service
Certifications or Licensure
Required: Extensive knowledge of claims management and processing, contracts and contractual interpretations for payment and benefit issues