VP, Claims and Customer Care

Title: VP, Claims and Customer Care Department: Operations Admin Support

Bargaining Unit: NBU Grade: N/A

Position Type: Exempt Hours per Week : 40

Position Summary

The VP, Claims and Customer Care provides oversight, leadership, and strategic direction to Claims and Customer Care operations to achieve and maintain service excellence in accordance with Company guidelines, client needs, financial parameters, and regulatory requirements.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities

• Oversees all aspects of claims, customer service and eligibility/enrollment operations to ensure client and member needs and expectations are consistently met; proactively addresses issues, concerns, or additional operational needs.
• Develops and implements strategic and tactical plans to enhance claims handling, eligibility management, and customer service operations delivery to improve client retention and profitability.
• Plans, controls, and coordinates claims, customer service, and eligibility/enrollment activity and workflow to maintain the highest professional customer service and technical standards.
• Mentors, coaches, and trains leadership staff consistent with Company values and mission.
• Develops staff through performance management, goal setting, training, and effective employee relations to ensure superior service is consistently provided.
• Implements and monitors internal systems, policies, and procedures to ensure efficient and effective operations.
• Oversees quality and quantity of work produced to ensure compliance with regulatory requirements and consistent delivery of client requirements.
• Establishes key performance indicators with reporting on and analysis of operational metrics for claim, customer service, and eligibility/enrollment operations.
• Prepares and distributes reports to stakeholders.
• Partners with Client Services to resolve customer/client service issues and assists in the successful implementation of new clients and changes for current clients.
• Oversees the management of expenses and labor allocations for assigned location to ensure operations remain within budget parameters; determines and implements appropriate course correction when needed.
• Partners with Client Services to address and resolve service issues or escalations with clients; attends client meetings as needed.
• Partners with information technology, project management, legal, finance, and other departments or teams to ensure compliant, efficient, and accurate service to clients.
• Maintains communications and effective working relationships with management and staff, clients, government agencies, unions, participants, attorneys, and consultants.
• Keeps abreast of industry changes affecting claims, customer service and eligibility/enrollment
• Performs other duties as assigned.

Minimum Qualifications

• Bachelor's degree in a business-related field and twelve years of experience working in claims and customer service operations leadership roles.

Or

• Associate's degree in business-related field and twelve years of experience working in claims and customer service operations leadership roles.
• Thorough knowledge of call center telephony, benefits, eligibility and claim adjudication principles, and reporting systems.
• Experience with call metrics and analysis, staffing models, workforce management, medical/dental terminology and ICD-10 and CPT-4 codes
• Experience in performance management according to call metrics. (KPI).
• Strong business acumen and a good understanding of business strategy in the insurance or related industry.
• Ability to effectively assess the long-term and short-term implications of decisions on the organization.
• Professional maturity with proven success nurturing internal and external relationships.
• Aptitude for creative, strategic thinking and experience executing process improvement measures.
• Exceptional team player with the confidence and integrity to earn client and internal team confidence quickly.
• Strong decision-making and organizational skills, with the ability to optimize the use of all available resources and deliver on multiple priorities.
• Proven ability to recruit, lead and motivate a team to balance staffing strength with profitability and growth.
• Experience managing a successful remote workforce.
• Excep