Posted on Jun 1, 2020 by CareFirst
Manages a Medicare Advantage Claims, Service, Enrollment and Billing, or Appeal and Grievance section which can including Supervisors, Customer Service Representatives or Claims Adjusters or Enrollment and Billing Technicians or Account Installation Technicians, and/or Clerical staff or may include oversight of an outsourced vendor for operations. Ensures daily operation runs with optimum efficiency and compliance to achieve all internal and external corporate goals and objectives. Responsible for ensuring high quality, timely, cost effective service, compliance and for maintaining high levels of customer and provider satisfaction and retention. Monitors section performance to ensure that all expectations are met while containing costs to meet financial goals. Recommends, coordinates, and directs solutions to improve operations and customer and provider service, working cross-functionally throughout the organization.
Under the general supervision of the Director, the Manager's accountabilities include, but are not limited to, the following:
1. Manages and leads or oversees daily activities of a large Operations area of business. Maintains a high level of member, provider, and account satisfaction and retention by leading associates responsible for handling inquiries, processing, claims or enrolling accounts for members, providers, group administrators, brokers, attorneys, CMS, and inquiries addressed to Senior Executive Staff and Medical Directors. Responsible for all aspects of the section's operation, including service to accounts, members, providers, claims adjustment and clerical workflows. Ensures that staff receive training, guidance, direction, support, and development, in order to obtain targeted results. Ensures that a consistent, high quality, timely, compliant, member focused and cost effective level of service is provided, and that all internal and external (ie CMS, NMIS, NCQA performance standards) goals and objectives are met.
2. Coordinates cross-functionally with a wide range of areas to meet customer needs, implement projects, addresses service/processing issues, improves quality of service, and implements useful and improved technology. Represents the Operational area on a wide range of corporate initiatives. Coordinates and develops policies, as well as the relationships, between the areas managed and other departments of the corporation (such as Sales, Medical Affairs, Systems Analysis and Planning, Network Management, Contract Compliance, Legal, etc.) in order to:
facilitate the exchange of information,
provide competitive analysis and product planning,
aid strategic initiatives,
ensure customer and provider service issues are taken into consideration
ensure intradepartmental initiatives are effectively coordinated and implemented
Ensures compliance of the areas managed with all regulatory requirements, mandates, policies and other requirements. Provides substantial day-to-day support for internal areas.
3.. Responsible for the resolution of highly complex and sensitive account/member/provider issues. Maintains direct customer and provider contact; personally handles the most complex and difficult inquiries and situations. Prepares and delivers formal presentations, conducts account visits, interacts on a face-to-face basis with current and prospective accounts.
4. Reviews and analyzes data, reports, survey results, complaints, appeals data and performance information to strategically determine allocation of staff and to consistently meet or exceed performance expectations. Develops strategies and executes detailed action plans to ensure excellent results and continuous improvement of service operation.
5. Responsible for associate development including Supervisor skills building. Creates, approves and discusses all performance plans and reviews for associates. Ensures adequate training, associate development and support. Identifies performance issues and develops plans to improve that performance. Uses action plans and career path tools where applicable. Ensures staff adhere to all policies, procedures and processes. Responsible for a positive and productive work environment and provides ongoing reinforcement and identification and resolution of problems. Hires and terminates employment; handles corrective action. Meets with staff at least bi-weekly.
6. Prepares and manages section's budget and allocation of resources.
Required: Bachelors Degree, or equivalent work experience. Five to eight years of progressive management or supervisory experience in a customer service, claims or enrollment and billing, non-clinical appeal and grievance related discipline with a minimum of 3 years of Medicare Advantage experience.
Abilities/Skills: Proven ability to manage a large section and multiple responsibilities. Exceptional oral and written communication skills. Customer-focused and results-oriented. Strong analytical/problem-solving abilities. Extremely well-organized. Demonstrated ability to achieve results under pressure. Strong interpersonal and team building skills. Innovative, flexible leader. Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Preferred: Health Insurance experience. Call center expertise, including knowledge of state of the art technology.
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