MINIMUM QUALIFICATIONS

• Bachelor’s degree and seven years of related work experience; or equivalent combination of education and related work experience.
• Five years of management/supervisory experience
• Expert experience developing and presenting actionable solutions to complex problems with C-Suite level.
• Effective written and verbal communication skill, including the ability to communicate and present complex issues in a concise and easy to understand manner.
• In-depth knowledge of managed care, PPO, HMO, Medicaid, Medicare Advantage, and commercial group health plans
• Strong working knowledge of claims adjudication systems (e.g., Facets, QNXT, Epic Tapestry, HealthEdge).
• Expert knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
• Intermediate knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.

• Design and lead execution of strategic plans to streamline operations, reduce claim turnaround time, meet accuracy requirements and improve first-pass adjudication rates.
• Ensure all claims are processed in accordance with member benefits, provider contracts, regulatory requirements, and internal policies.
• Drive operational quality programs, ensure we are adhering to industry standards and best practices, and support internal and external audits.
• Partner with IT department and external service providers to enhance claims platforms and integrate automation, AI, and data analytics tools where applicable.
• Ensure cost containment through fraud prevention, coordination of benefits (COB), subrogation, and provider contract enforcement.
• Encourage a culture of continuous improvement, from the proper documentation of current state processes to proposing new solutions consistent with the future state.
• Work with production leadership and business areas to develop relevant, timely, and effective training related to organizational changes and quality issues.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.
• Support relationship(s) with service providers as applicable.
  

  LI-Hybrid