Job Description :
The job establishes the overall strategic and operational plan for area of accountability and manages and develops all direct and indirect reports with responsibility for handling inquiries for all states outside of primary area and processing claims submitted by host providers within primary area. This position is responsible for directing the identification of enhancements and needed expanded capabilities of systems and operational change management. (If applicable: Directs ongoing Medicare Advantage Part C and Part D Center for Medicare and Medicaid Services (CMS) risk assessment, plan benefit filing on boarding, compliance audit activities, attestations, and mandated data filings.)
1. Provide leadership and oversight of management for claims operations. Participate in the formulation and execution of the division’s claims operations strategy and vision.
2. Establish, monitor and work with team to continuously improve on all aspects of claims operations. Direct the daily production activities of team members to deliver accurate, timely and efficient service to customers. Direct assigned claims processing, review and adjustments as well as all claims related activities.
3. Ensure all operational processes are in compliance with established quality standards, government and industry regulations, and client requirements.
-Accountable for CMS required reporting and operating a CMS regulated business in compliance with Medicare C&D regulations.
4. Direct all ongoing Blue Cross Blue Shield network sharing and ITS activities while actively engaging and advancing government compliant policy changes and ITS enhancements to the Association.
5. Identify, distinguish, and knowledgeably evaluate government regulatory changes and operational performance risks to formulate and synthesize operational direction for compliant performance and cross departmental efficiencies.
6. Direct Coordination of Benefits activity, including Other Party Liability, Medicare Secondary Payer, validation, special status updates, member outreach communication and investigation along with associated payment recovery activities and strategies to include Medicare Advantage and Part C and D as appropriate.
7. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience.
- Bachelor’s degree or 7+ years related experience
- 3 years management experience in Medicare, Medicare Advantage (if required)
- 7 years of experience in large operations environment
- 7 years of experience with insurance products principles, industry practices, and processes
- Master’s degree
- 5 years of experience of insurance product knowledge
- 5 years of experience in workforce development and resource management
- 3 years of experience marketing or selling services for operational capabilities
- 3 years of experience with project management
Knowledge, Skills and Abilities.
- Experience to effectively manage, direct, and motivate staff.
- Demonstrated track record of operational effectiveness.
- Strategic thinking and planning.
- Must be willing to travel to meet with clients, attend conferences as well as assist Sales with site visits to potential clients.
- Financial and budget/expense management experience.
- Ability to handle multiple priorities and the ability to identify, analyze and solve problems independently.
- Strong organizational and analytical skills
- (If required: Ability to interpret and understand complex government/CMS regulations.)
- (If required: Comprehensive knowledge of Medicare regulations, law and coverage issues.)
IV. SCOPE OF RESPONSIBILITY:
Does this role supervise/manage other employees? Yes
V. WORK ENVIRONMENT:
Is Travel Required? Yes
Referral Level Payout 3
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