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J207949

Director Claims Administration

HM Insurance Group

  • Company Reinsurance Solutions
  • Home, PA
  • Claims
  • Full time
  • Day (United States of America)

Company :

HM Insurance Group

Job Description : 

GENERAL OVERVIEW:  

This position is responsible for the operational results of HM Insurance Group’s employer stop loss insurance product.  The incumbent establishes the overall strategic and tactical operational plan for his/her areas of accountability to support corporate strategies and initiatives in the stop loss product line and directs the management staff in the discharge of their duties. The incumbent is expected to be a subject matter expert in subrogation, PPO networks and out of network savings solutions, individual case management and technical claim knowledge.  It also provides strategic direction to the management team, including guidance in development of tactical plans for the day to day operations of the unit. This includes operational processes and procedures, cost containment activities, quality assurance activities and staffing. This position oversees the operational aspects of national strategic partnerships with Managing General Underwriting organizations (MGUs) and other Blue Plans and/or Blue owned TPAs nationally.

ESSENTIAL RESPONSIBILITIES: 

1. Effective Communication/Personnel Management

  • Promote an environment of growth and development consistent with corporate business plan and goals.
    • Manage turnover, affirmative action plan goals and staffing levels to plan.
    • Recruit, develop and train high caliber staff.
    • Budget preparation and accountability for unit cost.
    • Provides ongoing performance feedback formally and informally. 

2. Provide strategic direction to the management team, including guidance in development of tactical plans for day to day operations including:

  • Develop procedures and processes that utilize technology to ensure proper handling of claims within corporate turn-around goals and corporate financial and technical quality goals, utilizing cost containment programs as needed.
  • Communicate risk evaluation for shock claim information during the new business and renewal underwriting processes.
  • Develop procedures and processes for evaluation of potential claim notices including Case Management Oversight policies and procedures.
  • Develop an array of vendors to provide cost containment services to HMIG’s TPA/MGU partners for Centers of Excellence, out of network discounting and hospital bill audits as well as subrogation recovery. These cost containment features have a direct impact on reserves and loss ratio for both HMIG underwritten business and MGU strategic partners.
  • Participate on the Stop Loss Product Team where team expectations are to implement HMIG’s annual strategic initiatives and business objectives, manage the TPA approval program as well as monitor and evaluate product performance (financial, operational and market).
  • Develop quality assurance programs for all functions within the unit ensuring that programs effectively identify error trends and training needs. This includes development of training manuals, quality bulletins and ongoing procedural documentation to ensure that operational consistency exists as well as development of training plans and staff training for new hires as well as existing staff.
  • Develop processes and procedures for the Customer Reporting group ensuring that all HMIG stop loss customers whose underlying plan claims are administered by Highmark, Inc. receive accurate monthly stop loss reporting.
    • Define opportunities for workflow and system improvements with concomitant expense reductions.
    • Approve all extra-contractual and litigation settlements.
    • Oversee administration of reinsurance treaties from submission to reimbursement.
    • Perform operational reviews annually to ensure these activities are effective and efficient. 

3. Oversee MGU strategic partnerships to ensure that the stop loss claims are handled in accordance with underlying plan provisions and stop loss policy provisions.

  • Review notice of potential claim information and subsequently addressing any issues.
  •  Review of claims over the MGU partner’s authority level on an ongoing basis and formal review of MGU partner’s procedures for handling claims to ensure they are consistent with industry standards comply with underlying plan and stop loss policy provisions as well as verifying that the appropriate cost containment programs are in place and utilized effectively.
  •  Perform periodic on-site audits of the strategic partners to ensure that overall operations comply with industry standard and HMIG expectations.

4. Oversee strategic partnerships with Blue Plans and/or Blue owned TPAs where HMIG is the issuing stop loss carrier and underlying plan claim administration is performed by the Blue Plan as well as strategic partnerships where HMIG is operating as an MGU on behalf of the strategic partner where the partner is the issuing stop loss carrier as well as the underlying plan claim administrator. This requires ensuring that HMIG complies with all internal day to day operational procedures as well as any additional operational requirements of the strategic partner HMIG represents.

5. Other duties as assigned or requested.

QUALIFICATIONS:

Minimum

Preferred

  • Bachelor’s degree
  • 5 years experience as a manager
  • 5 years experience in management of group Excess Risk claims
  • 7 years experience managing in an insurance operations environment with bottom line production and unit cost accountability
  • 7 years experience utilizing insurance principles, industry practices, operational and system processes, quality control techniques, audit and compliance requirements, resource management and financial management skills.
  • 1 years experience presenting and communicating with internal and external customers
  • 5 years experience presenting and communicating with internal and external customers
  • High standard of professional conduct
  • Excellent business writing skills
  • Ability to maintain confidential information
  • PC applications skills
  • Experience in team interactions and team building
  • Ability to quickly identify and provide recommendations on issues
  • Excellent leadership skills and ability to relate to all levels of management and staff as well as individuals external to the corporation

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

WFA - Work From Anywhere

100% - Remote

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Referral Level 3:

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.


As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice


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