Manager, Claims Operations

MANAGER, CLAIMS OPERATIONS

The Opportunity

The Manager, Claims Operations, leads all aspects of the claims adjudication process along with collaborating with other department leaders and vendor partners to deliver excellent service to our clients, members, and providers. This includes the development and execution of strategies and methodologies for efficient and effective claims processing which delivers on timeliness and quality of claims processing. The ideal candidate combines empathy and data-driven decision-making to make policy decisions, create and document standard processes, manage a team to production targets, and scale operations. The Manager, Claims Operations reports to the Director, Claims Operations.

What you’ll do

• Oversee the day-to-day claims operational processes, including inventory management of claims, to meet quality and timeliness standards.
• Responsible for the data integrity of the claims system to ensure files are received and processed. If there are identified issues, the Claims Manager is responsible to resolve and correct with upstream suppliers and downstream customers as needed, throughout the lifecycle of the claims process, this includes claim intake, provider data and logic, claim adjudication, quality outcomes and downstream payment systems.
• Responsible for developing, maintaining, and training written policy and procedures for claims processing.
• Responsible for developing, managing, and maintaining production and staffing plans to support fluctuating claims and plan implementation volumes, driven by new business, new products, seasonality, and/or department changes that are designed to meet or exceed the defined performance standards.
• Define team and individual KPIs and manage the team to execute the operational strategy and annual goals.
• Coach and develop staff to ensure adherence to timeliness, quality standards, and company values.
• Identify and Implement improvements to create capacity, reduce claims inventory, increase auto adjudication rate, improve quality, reduce the cost of a claim, and maximize claims compliance efforts.
• Inspire and guide direct reports and cross-functional stakeholders through change by effectively applying change management principles.
• Proactively escalate known risks, potential exposures, and concerns with supporting data, proposed solutions, and timelines.
• Demonstrate initiative in investigating potential errors and reported business incidents. Provide stakeholders with timely responses, root cause analysis, and resolution.
• Provide reporting with accompanying analysis of operating metrics and performance measures for claims operations.
• Oversee and actively participate in the planning, implementation, and deployment of new products, initiatives, workflows, and strategies designed to enhance the services offered to our clients. Responsible for designing and implementing action plans to facilitate required changes.
• Maintain up-to-date industry knowledge related to claims processing, including compliance requirements and claim integrity/fraud components, and other pertinent industry standards.
• Demonstrate initiative in investigating potential errors and reported business incidents. Provide stakeholders with timely responses, root cause analysis, and resolution.
• Responsible for continuous quality improvement and establishing and ensuring adherence to internal performance targets.
• Responsible for effectively managing confidentiality policies, PHI and other sensitive data or information in compliance with company and regulatory guidelines.
• Manage requests for audits and other compliance requirements. Maintain oversight of the performance of internal controls and changes to the environment throughout the year to determine if adjustments are required to internal controls to maintain an effective level of risk mitigation.
• Provide monthly reporting with accompanying analysis of operating metrics and performance measures for all claims operations areas.
• Develop and continually evaluate processes, systems and explicit measurements that ensure timely and accurate execution of organizational objectives, as well as ensuring client and member satisfaction and reducing costs where possible.
• Responsible for proactive collaboration with other internal departments on developing options for meeting custom client plan and benefit designs, designing, and implementing solutions to meet new product requirements, and resolving escalated or complex issues, complaints, grievances, or risk issues.
• Direction and monitoring of direct reports to include setting performance expectations, creating SMART goals, assigning task and project work, performance management, and evaluations. Actively engage with direct reports to validate desired progress and results.
• In collaboration with HR, responsible for hiring, developing, training, mentoring, and retaining high quality, productive employees.

What we expect from you

• Degree in business, health care, or public healthcare administration
• 3 years’ experience with people management responsibilities
• 3+ years’ experience in Supervising/Management of a claims Operational team
• fast-paced, transactional based environment
• Claims adjudication platform configuration experience.
• Experience with vendor data connectivity management
• Experience in the administration of self-funded TPA healthcare plans preferred.
• Experience with Virtual Benefits Administrator (VBA) preferred.
• Experience with stop loss management, flexible spending, and HRA/HSA administration preferred.

Skills, Knowledge, and Abilities

• Strong understanding of claims adjudication processes and platforms
• Excellent coaching and staff management skills
• Effective communication skills (both in oral and written)
• Initiative-taker and ability to work independently and collaboratively.
• Ability to think strategically with appropriate level of detail analysis to plan and execute.
• Ability to manage multiple priorities in a fast-paced environment.
• Proven ability to exhibit an initiative-taking approach to seeking solutions.
• Exceptional customer service and people skills
• Excellent problem-solving and influencing skills to determine root causes and develop effective solutions.
• Strong organizational, self-motivation, and decision-making skills
• Proficiency using Microsoft programs (Word, Excel, PowerPoint)

We make healthcare EZ!

Additional Opportunity Details:

Target Base Compensation Range for this role is $90,000-$125,000*

* Factors that may be used to determine your actual salary include your job specific skills, education, training, job location, number of years of experience related to this role and comparison to other employees already in this role.

Employee benefits are part of the competitive total rewards package that HealthEZ provides to you. Our comprehensive benefits program includes health benefits, retirement plan (401k), paid time away, paid leaves (including paid parental leave) and more.

HealthEZ recognizes its responsibilities under federal, state, and local laws requiring non-discriminatory employment practices. All employment decisions, practices and procedures will be carried out without regard to race, color, creed, religion, sex (including pregnancy), sexual orientation, national origin or ancestry, age, marital status, disability, family status, status with regard to public assistance, or any other characteristic protected under applicable local, state, and federal laws.

HealthEZ is proud to be an equal opportunity employer.