Mgr, Claims Operations

Manages data collection/interpretation by developing and maintaining departmental reports, creating best practice on inputting claims details into claims database, and obtaining and distributing resources to aid the setting up and maintenance of files on all outside referral patients. Implements solutions to improve referral data quality, oversees processes used to verify referrals and/or authorizations, and reviews completed, highly-complex reports. Implements changes to compliance protocols and acts as a primary contact for updates to relevant compliance standards, regulatory policies, laws, or accreditation standards. Oversees the development of goals and priorities for strategic projects, enforces a structured approach to resolve process/system issues and improve operating efficiency, and ensures performance metrics are tied to strategic initiatives. Manages member identification/support processes by implementing and maintaining the processing of insurance claims, and overseeing the development of resources to help others create solutions to claims and benefits inquiries.

• Provides developmental opportunities for others; builds collaborative, cross-functional relationships. Solicits and acts on performance feedback; works closely with employees to set goals and provide open feedback and coaching to drive performance improvement. Pursues professional growth; develops and provides training and development to talent for growth opportunities; supports execution of performance management guidelines and expectations. Leads, adapts, implements, and stays up to date with organizational change, challenges, feedback, best practices, processes, and industry trends. Fosters open dialogue amongst team members, engages, motivates, and promotes collaboration within and across teams. Delegates tasks and decisions as appropriate; provides appropriate support, guidance, and scope; encourages development and consideration of options in decision making.


• Manages designated work unit or team by translating business plans into tactical action items; oversees the completion of work assignments and identifies opportunities for improvement; ensures all policies and procedures are followed. Aligns team efforts; builds accountability for and measuring progress in achieving results; determines and ensures processes and methodologies are implemented; resolves escalated issues as appropriate; sets standards and measures progress. Fosters the development of work plans to meet business priorities and deadlines; obtains and distributes resources. Removes obstacles that impact performance; identifies and addresses improvement opportunities; guides performance and develops contingency plans accordingly; influences teams to execute in alignment with operational objectives.


• Manages the payment of claims by: reviewing internal controls to ensure claims are being that all expenditures are properly adjudicated and paid on time in accordance with contractual benefits; and addressing highly sensitive issues on behalf of team members concerning the delivery of claims information (e.g. pay decisions, referral matching) to adjudicators, vendors, and stakeholders on payment approval/denial and provides oversight on addressing escalated claims payment issues.


• Addresses compliance and needed policy changes by: implementing changes to policies and procedures which support compliance protocols; acting as a primary contact for updates on relevant documentation, policies, and processes related to referrals, authorization processes, utilization review; using advanced knowledge of the field and critical understanding of other claims processes to ensure relevant compliance standards, regulatory policies, laws, or accreditation standards are incorporated into compliance training; and providing expertise on the analysis of claims activity and submission of reports to appropriate regulatory bodies.


• Manages data collection/interpretation by: developing and maintaining system configuration changes, reviewing completed system configurations, and testing changes to ensure they are error-free; creating best practice on inputting claims details, reviewing, or auditing data in claims databases across various regions; and aligning teams and holding them accountable for using methods to create and maintain databases and automated tools which improve workflow.


• Supports member identification/support processes as directed by: implementing and maintaining an effective utilization review program to prevent excessive payments; and overseeing the development of resources to help others develop resolutions that should be proposed to providers and members when addressing claims and benefits inquiries.


• Manages improvements to operations and technology processes by: defining issues and overseeing the development of goals and priorities for strategic projects with executive leadership designed to remediate issues for impacted groups and improve claims and referral operating efficiency; applying a structured approach for identifying root causes and implementing solutions to improve the performance of claims, referral, or other system processes; and ensuring performance metrics used to monitor the success of strategic improvement projects are tied to strategic department initiatives.


• Manages the intake and management of referral requests by: developing methods used by others to collect inpatient medical data (e.g., charts, records) from internal staff or clinicians, outside providers, and members to determine coverage/benefits and make a referral; implementing solutions to improve data quality and accuracy during the entry of patient data (e.g., admission, discharge, electronic medical record, demographic) in the referral system so that providers can ensure coordination of care; and reviewing and providing feedback on completed, highly-complex reports; and ensuring referrals are being processed according to quality standards, across multiple teams.