Manager, Claims Operations

POSITION SUMMARY

The Manager, Claims Operations is responsible for managing the day-to-day operational functions of the Refund, Rapid Response (RRT), Prompt Pay, Short Term Disability, Plan Building, and Plan Testing teams.

ESSENTIAL FUNCTIONS

• Maintains collective responsibility for the management of services provided by the Refund, Rapid Response (RRT), Prompt Pay, Short Term Disability, Plan Building, and Plan Testing teams. Additionally, responsible for monitoring metrics and operations within these teams.
• Responsible for implementing best practices based on company goals.
• Identify strategic opportunities based on financial analysis and projections, cost/benefit identification and analysis.
• Provide support, guidance, leadership, and motivation to promote maximum performance.
• Responsible for preparing reporting and analysis that is consistent with defined standards and processes.
• Provide technical guidance to staff on claim investigation, reserving evaluation and resolution of claims.
• Partner with analytical team to produce necessary results and trending reports for leadership.
• Review high dollar appeals, medical review referrals, and subrogation cases from members, providers, and other entities.
• Manage all aspects of the day-to-day operations of claims production.
• Interact extensively with various parties involved in the claim process.
• Remain current and aware of impact on claims management strategies.
• Collaborate with other Claims and business leaders to define and drive enterprise initiatives.
• Assist or prepare files for subrogation.
• Create an environment that encourages and values the opinions of others and promotes sharing of information and ideas.
• Oversee monitoring and tracking of individual and unit's performance against established productivity and quality goals & metrics.
• Lead, coach, motivate and develop. Responsible for one-on-one meetings, performance appraisals, growth opportunities and attracting new talent.
• Clearly communicate expectations, provide employees with the training, resources, and information needed to succeed.
• Actively engage, coach, counsel and provide timely, and constructive performance feedback.
• Other duties as assigned

EDUCATION

• Bachelor’s degree or equivalent work experience required.

EXPERIENCE AND SKILLS

• At least 5 years of TPA or group health insurance experience including at least 3 years supervisory experience and successfully demonstrated leadership competencies required.
• In-depth knowledge of Claims, Benefits and administrative skills & processes required.
• Intermediate level work experience with Microsoft Office, Word, Excel, Access, and Power Point software applications. 
• The ability to easily learn other software and systems.  Be able write business correspondence and procedures.

POSITION COMPETENCIES

• Accountability
• Communication
• Action Oriented