Manager Operations and Claims Risk Analysis
Blue Cross Blue Shield of Tennessee - Chattanooga, TN

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The incumbent has accountability for the customer service, claims adjudication, claims risk analysis and Medicare Secondary Payor (MSP) determination for Medicare Advantage and the Medicare Supplement lines of business. The incumbent is responsible for claims transaction processing that fully complies with Federal requirements. In addition, the incumbent must assure claims and service policies and procedures are in place to meet Federal standards and audit requirements. Incumbent must also assure that claims operations meet plan bid specifications. The incumbent must assure that claims operations are monitored, analyzed, and enhanced, where necessary, to meet financial performance expectations for Medicare Advantage. The incumbent must assure that performance of claims processing and customer service is of sufficient quality to meet performance expectations for enhanced Federal reimbursement for quality performance. Incumbent is also responsible for providing analysis of claims information that supports quality goals and care management initiatives of the Senior Care Division. This position also has accountability for claims risk analysis under Federal Programs which affect the profitability and compliance for this line of government risk business. Job Duties & Responsibilities Develop, communicate and execute short term and long term customer service strategy throughout the unit to achieve profit and growth objectives. Drives key customer service initiatives that address product strategy and profitability objectives Introduce new functions and responsibilities to areas that will directly support achievement of higher quality ratings from Federal agencies Design project work plans for new service quality initiatives in the Medicare Advantage unit to meet HEDIS and other CMS Star ratings measures which directly affect Medicare Advantage revenue. Monitor claims processing activity for claims and enrollment fraud, waste and abuse. Recommend the development of additional features/capabilities for enhanced customer service; initiates action plans to improve or maintain performance. Develop and drives key systems strategy to improve profitability within the Medicare Advantage and Medicare Supplement lines of business. Manage strategies related to multiple claims processing payment objectives which includes Processing claims in compliance with requirements outlined in various Original Medicare and Medicare Advantage manuals (Medicare Managed Care Manual, Medicare Claims Processing Manual, Medicare Benefit Policy Manual, Medicare Program Integrity Manual, Medicare Secondary Payment Manual, Medicare National Determinations Coverage Manual) while using BCBST's commercial claims payment system (Facets) and Medicare's PC PPS Pricers for inpatient, SNF, home health, inpatient rehab, inpatient psychiatric, and outpatient services. Guide the process of analyzing claims processing capabilities and future enhancements. Works collaboratively with corporate underwriting/actuarial leadership to develop data and information that supports financial results. Ensure the accuracy and timely update of data populated on Medicare's eligibility database regarding other health insurance that is primary to Medicare (MSP activity) Oversee relations with vendors providing services to enhance claims payment functionality and to assist with appropriate payment from CMS. Such vendor functions include claims integrity services and Medicare Secondary Payer verification. Oversee customer service activities for both Employer Group products and Individual products Direct and oversee multiple departmental staff, resources, and operations within approved operating budgets. Assure the delivery of 'world class' service to members, groups, brokers and providers that meet the expectations of the marketplace and of the Centers for Medicare & Medicaid Services (CMS). Successful alignment of individual performance objectives and goals for both the Manager and their direct reports to meet Division and Corporate objectives and any other accrediting entity, e.g. NCQA, URAC, MTM. Required to meet internal and external guidelines as well as applicable federal and state mandated statutes (CMS, NAIC, TDCI, BCA, COBRA, including Title VI guidelines, etc.) as applicable. Comprehensive knowledge and application of laws, regulations, and contractual provisions, corporate policies, processing guidelines, underwriting guidelines and departmental polices. Act in a fiduciary capacity to limit the amount of risk to the company. Proactively identify, develop and implement process improvements to minimize Federal risk exposure for BCBST. Monitor information and make recommendations to senior management and/or appropriate committees to reduce financial exposure and improve the quality of corporate processes that affect the delivery of health care to plan members. Hire, develop and provide motivational leadership and training to department personnel in order to achieve a targeted level of competence, quality control and career development Proactively build and maintain effective working relationships with internal and external business partners, working closely with those partners as necessary to achieve desired results (Marketing, Legal, BCA, other Blues Plans, CMS, Providers, Group Administrators, Brokers, etc.) Manage inquiry escalation or dispute functions as applicable (grievances, appeals, etc.) Contribute to or maintain On-Line Help programs as applicable, including communication and education. Facilitate, coordinate and conduct meetings in order to develop and or improve policies, procedures and workflows. Operate in a rapidly changing healthcare environment. Support diversity initiatives with the organization. Ability to travel
Education Bachelor's Degree or equivalent work experience required. Equivalent defined as 10 years in the industry. Experience 10 years in an insurance company operational area; preferably 3 - 5 yrs in Government products area. Minimum 5 years experience in a leadership role required. 3 to 5 years experience managing Traditional Medicare or Medicare Advantage Plans preferred Claims and or Customer Service Operations experience is preferred Strong knowledge of the Medicare Advantage PFFS and PPO MA and MAPD programs and benefits. Advanced working knowledge of Medicare reimbursement policies and payment methodologies Extensive working knowledge of the Traditional Medicare FFS Program Extensive background and experience working in the CMS regulatory environment Previous experience in Traditional Medicare/Medicare Advantage claims and service is preferred. Extensive knowledge of Medicare supplement/Medigap Benefit Plans Extensive working knowledge of how to process exhausted lifetime SNF and inpatient claims utilizing Medicare reimbursement policies and payment methodologies Extensive understanding of claims medical loss ratios and the ability to impact claims utilization. Extensive understanding of COBA processing and crossover claims Previous experience with UM/Case Management, managed care and disease management Knowledge of Part D programs and PBM coordination with members and pharmacy providers Extensive working knowledge of claims processing systems and the interfaces with Medicare payment software Experience with CMS on site visits and audits as well as corrective action plans and disclosure of potential compliance issues Skills/Certifications Proven ability to conduct root cause analysis, plan, organize and coordinate multiple projects. Strong interpersonal skills. Strong analytical and decision making abilities. Proven ability to speak in public and conduct effective presentations. Extensive understanding of IVR technology is preferred. Prior Service Operations management experience preferred.

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