At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.

Come join us and be part of a purpose driven company who is  invested in your future!

Job Summary

This Position Is Responsible For Managing One Or More Areas In Subscriber Services.

PLAN OPERATIONS
JOB PURPOSE: This position is responsible for managing one or more operational areas in Plan. This role is responsible for managing production teams that enter data, determine eligibility, and interact with state regulator systems related to provider independent disputes. This role is responsible for ensuring the end-to-end operations are compliant with the state laws and regulations including timelines and accuracy. Additionally, establishing processes, improving processes, and providing reports to senior leaders and specific clients will be key for this role.

1.Responsible for daily supervision which includes coaching, developing, education and directing activities of employees supervised.
2.Responsible for staff providing processing of additional paychecks and statistical adjustments, research and resolution of checks, logging and distribution of special checks request to and from Finance, research and resolution of approvals, timely resolution of all outstanding accounts receivables, out of balance conditions, and system posting of manually written checks.
3.Responsible for staff ensuring resolution of suspended claims pending approvals, claims identified as inaccurate/ incomplete.
4.Responsible for staff overseeing quality audits for claims, suspense and adjustments.
5.Responsible for staff monitoring financial reports to ensure claims are paid or funds are returned within time limits.
6.Assist in review of audits from internal/external sources; initiate corrective action and monitor until resolved.
7.Assist in review of fraudulent claims, including analysis of original claims and documentation, approving or rejecting pending claims, initiating claims holds and referring to the Legal Department as appropriate.
8.Monitor unit and departmental performance standards initiating improvements.
9.Responsible for staff managing and coordinating processing, adjudication and expedient payment of BCBS and supplemental claims; prompt, efficient and effective servicing of subscriber group and provider inquiries; coordinate and direct premium billing and accuracy of membership files; assure tight level of customer (group and individual member) and provider satisfaction in all of these facets in a cost effective manner.
10.Responsible for staff interpreting Plan benefit contract for assigned accounts and establish administrative policies and procedures to ensure accurate adjudication; has final authority up to prescribed limits for payment or rejection of unusual or exception claims.
11.Responsible for staff implementing and administering appropriate claims adjudication policies, procedures and utilization safeguards.
12.Responsible for staff developing and implementing operating procedures required for departmental performance monitoring and control.
13.Responsible for staff preparing of routine, regulatory and special reports.
14.Serve as liaison with internal/external departments.
15.Responsible for staff responding to specific cases and problems with group administrators or Provider to resolve claim problems, special group needs and review administrative procedures and modify as required. Ensure problems are handled within corporate guidelines.
16.Ensure organization of the department and implement changes as needed to maintain and improve performance.
17.Prepare departmental budget ensuring expenditures adhere to corporate and divisional budget.
18.Participates in workgroup committees.
19.Responsible for staff managing the operational unit by coordinating, controlling and overseeing systems programming, design, production, fulfillment and issuance of ID cards.
20.Assist marketing management in setting up procedures on new groups and resolving significant membership file and/or policy issuance problems with existing groups.
21.Responsible for staff developing functional level projects plans disseminate plans to others, manage multiple corporate or divisional initiatives, complex

projects and communicate with all levels of management.
22.Monitor, maintain and approve Performance Guarantees.
23.Responsible for staff monitoring and validating ID cards to ensure verbiage and design structure are consistent with BCBSA Brand Regulations.
24.Communicate and interact effectively and professionally with co-workers, management, customers, etc.
25.Comply with HIPAA, Diversity Principl