Job Description :
This job manages internal Quality Assurance functions, including stop loss reviewer and examiner claim audits, nurse audits, cost containment, stop loss underwriting and other various quality audits. Manages the claim audits of external MGU partners and TPA partners.
- Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Manage the development, design, and ongoing operation of all internal Quality Assurance functions for all stop loss activities, including claims, nurse, cost containment, and stop loss underwriting. Provide management with monthly quality results identifying the strengths and weaknesses of the functional area and provide recommendations for improvements/changes needed to achieve Corporate Strategic Objectives.
- Oversee the audit programs for MGU partners and TPA partners, ensuring that partner activity is in compliance with HMIG corporate practices and procedures. Make recommendations as needed, with appropriate follow through on all recommendations. Address deficiencies and/or weaknesses and coordinate corrective action which may involve changes to processes, systems, and requires ongoing communication with internal MGU Relations department, sales offices as well as the MGU and TPA partners.
- Conduct audits to ensure proper internal Cost Containment procedures are followed by both the Claims staff and the Clinical/Cost Containment staff, including but not limited to: verification that PPO discounts exist or alternate cost containment methods were employed, identification of potential subrogation opportunities with appropriate internal action, identification and proper handling of other issues that impact stop loss claims payment and directly impact loss ratios with appropriate internal action.
- Conduct audits to ensure all specific stop loss claims processed by HM Insurance Group are processed in accordance with the terms of the applicable Summary Plan Description and Stop Loss Policy.
- Other duties as assigned or requested
- Bachelor’s Degree in Business Administration/Management
- 5 – 7 years in Claims Administration
- 3 – 5 years in Management
- 0 – 1 year in Audit
- 0 – 1 year in the Insurance Industry
LICENSES AND CERTIFICATIONS
Language (Other than English)
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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.
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