Job Description :
This job leads the administration and delivery of operations for Highmark’s commercial and government-sponsored business and is responsible, where applicable, for overseeing the administration of Application Service Provider/Business Process Outsourcing-Off Shoring (ASP/BPS) operations purchased by HMHS’s Plan customers. In doing so, the incumbent requires broad and deep market, strategic and regulatory subject matter expertise and ability to quickly lead operational change initiatives required to meet a market opportunity or threat. Oversees the end-to-end administration of market-facing operational services and includes, but is not limited to, eligibility, enrollment, disenrollment, customer installation and maintenance, fulfillment, member and provider services, claims and adjustment processing, premium billing, and appeals and grievances. Works closely with the Clinical Service Operations, Provider Operations, Audit, Legal and Finance organizations. Understands and delivers on all regulatory requirements, including STARS, for Medicare Advantage Medicaid and the Affordable Care Act, all employer and commercial customer and HMHS customer SLAs and performance guarantees, and all federal, state and BCBSA mandates impacting the respective business segment or region. This role requires strong strategic thinking and presentation skills, experience analyzing and interpreting diverse and complex operational and financial data and demonstrated experience leading large scale initiatives and projects. The incumbent also has responsibility for leading the development of Highmark HPO’s Customer Experience strategy.
- Recommend process and technical solutions aimed with driving efficient and effective outcomes.
- Collaborate with internal and external clients on activities that safeguard the business from risks.
- Communicate market requirements and performance expectations effectively across all levels of employees and functions in HPO. Implement and execute the organization’s mission, vision, and values, and maintain high employee engagement across directly managed and matrixed resources. Provide business, operational and technical guidance and knowledge to others within the HPO organization and other business units and organizations. Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- Oversee the administration and delivery of operations for Highmark’s commercial and government-sponsored business and is responsible, where applicable, the administration of BPS operations purchased by HMHS’s Plan customers. This role has direct accountability for overseeing the end-to-end administration of market-facing operational services and includes, but is not limited to, eligibility, enrollment, disenrollment, customer installation and maintenance, fulfillment, member and provider services, claims and adjustment processing, premium billing, and appeals and grievances.
- Understand and deliver on all regulatory requirements, including STARS, for Medicare Advantage Medicaid and the Affordable Care Act, all employer and commercial customer and HMHS customer SLAs and performance guarantees, and all federal, state and BCBSA mandates impacting the respective business segment or region. Work closely with the Clinical Service Operations, Provider Operations, Audit, Legal and Finance organizations to ensure consistent and compliant end-to-end performance for Highmark customers.
- Provide strong strategic thinking and presentation delivery by analyzing and interpreting diverse and complex operational and financial data and leading large scale initiatives and projects that ensure a consistent, compliant and market-leading end-to-end experience for Highmark customers..
- Serve as a trusted advisor to P/L and Sales leadership, Product Management and Finance on matters requiring or impacting operations or delivery of operational services to customers of Highmark or HMHS customers.
- Lead certain high-profile initiatives that require a broad application of operational and business knowledge required to drive change or to address a market threat or opportunity.
- Lead the development and execution of HPO customer experience to human center design strategy.
- Other duties as assigned or requested.
- 10 years of experience utilizing insurance principles, industry practices, operational and system processes, quality control techniques, resource management and financial management skills
- 7 years of experience of management experience in commercial and/or regulated government business healthcare or insurance with experience in driving change and process improvements
- 7 years of experience evaluating technology for implementation in gaining improved services and re-engineering process and procedures
- 7 years of experience utilizing various industry laws and regulations such as HIPAA, Sarbanes Oxley compliance, Act 68 and Act 147
- 7 years of experience presenting an communicating with large audiences, executives, board members and customers
- Experience with BCBSA and CMS
- Experience with Medicare, Medicaid, commercial insurers
- Experience with matrixed organizational culture
- Experience leading major change initiatives
LICENSES AND CERTIFICATIONS
- Communicate effectively both written and verbal. Can adjust based on audience level
- Critical thinking and data analytics for decision making
- Continuous Process Improvement and Project Management Oversight
- Solid negotiation and influencing skills
- Effective presentation and consultative selling skills with external parties (e.g., employers, HMHS health Plan customers)
Language Requirement (Other than English)
25% – 50%
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)
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 position 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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