Senior Manager, Operations Claims

POSITION SUMMARY

The Sr. Manager of Operations has responsibility for providing leadership and management in the areas of claims-related services, including processing, auditing, research, and resolution, reporting and process improvement.  This position will be responsible for the coordination of Gold Coast Health Plan’s (GCHP"s) outsourced claims processing transaction functions as well as the overall daily management of GCHP"s internal Claims and Analytics team. The internal Claims and Analytics team’s primary focus is on claims and operational analysis, research, projects, auditing, high dollar claims approval, partnering with the G&A department with Provider Disputes and supporting all other GCHP departments, while transaction processing and adjustments is performed by GCHP’s vendor. The Sr. Manager of Operations, Claims will ensure that the claims payment process adheres to regulatory requirements, that payments are made according to benefit and contract terms, and that providers have a high level of satisfaction with claims payment performance. The Manager reports directly to the Executive Director of Operations and partners with other departmental managers and external vendors on all strategic and tactical matters as they relate to provider claims and payments

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

•    Lead and direct the claims management process, driving execution of best practices and related initiatives designed to provide a high level of efficiency and accuracy.

•    Ensure the processing of claims payments adheres to regulatory requirements and that payments are made according to benefit and contract terms; work to minimize the volume of pended and adjusted claims

•    Ensure effective and efficient operational processes and regulation adherence including validation that all new policies and procedures are implemented

•    Provide subject matter expertise in project management and other areas of expertise

•    Lead, coordinate and complete operational improvement projects across various functional areas within and outside of Gold Coast Health Plan

•    Own end-to-end process improvement: including definition of need, project plans, status updates, reporting and achieving results

•    Establish operating metrics and daily, weekly, and monthly scorecards to manage ongoing operations 

•    Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes, enhanced management reporting and identification of process improvements 

•    Develop collaborative relationships with and confirms business partners can execute day-to-day responsibility for operations 

•    Develop collaborative relationships with matrixed partners and vendors

•    Inform and advise management regarding California Department of Health Care Services’ current trends, problems and activities to facilitate both short- and long-range strategic plans to improve operational performance

•    Own operational accountability for the successful system conversions, where applicable

•    Identify and resolve technical, operational, and organizational problems inside and outside health plan

•    Lead teams to resolve business problems that affect multiple functions or disciplines

•    Lead and influence staff by fostering teamwork and collaboration, driving employee engagement, and leveraging diversity and inclusion

•    Drive high-quality execution and operational excellence by communicating clear directions and expectations

•    Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate

•    Monitor and provide oversight to delegated entities with regard to claims compliance from a regulatory and contractual perspective

•    Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes and management reporting

•    Prepare requested materials for internal and external regulatory audits and legal requests

•    Address escalating claims issues from providers and members to f