Demonstrates knowledge and understanding of benefit administration for self-funded healthcare plans
Ensures that claims are processed and paid in accordance with benefit plans, pricing agreements, and required authorizations.
Manages the inventory of claims against standard service level agreements (SLA’s)
Educates and mentors claims staff to ensure proper application of client benefit plans to claims processed, at the required quality and production metrics, including establishing performance plans for those falling below expectations with appropriate coaching and mentoring to achieve improvement.
Provides reports to department leaders on claim inventory, production, turn-around lag, and quality metrics
Develops policy and procedures to ensure that benefit plans and claim standards are properly administered; assists in developing policies and procedures for operations, and monitors claim staff for compliance
Accountable for positively influencing the morale of the department employees, including setting achievable goals, fostering teamwork by involving team in the design/implementation of solutions to problems
Responsible to establish annual goals for staff that align with organization strategies and personal growth and can provide timely and constructive feedback on performance
Is a liaison for the claims on various projects and/or initiatives including testing needs to support system implementations and/or upgrades
Performs other duties as deemed essential and necessary
Qualification
KnowledgeLeadershipAnalytical SkillsExperienceEducation and ExperiencePast Training ExperienceExperience working at TPAExperience with self-funded plansIf not in the Buffalo areaLeadership Skills & Behaviors
Required
Knowledge: Thorough understanding of insurance policies, claims handling processes, and legal requirements associated with claims.
Leadership: Strong leadership and team management skills, with the ability to effectively manage and motivate a team.
Analytical Skills: Ability to analyze claims data and make informed decisions based on findings.
Experience: Previous experience in claims processing or a related field, including supervisory experience.
Understands health insurance benefit administration in a Self-Funded environment
Ability to read and understand various forms, documentation, files, and information with the department.
Education and Experience:
Candidate must have at least 3 years of experience with self-funded health care plans, and processing in a TPA environment
Candidate must have at least 3 years of experience supervising a claims team
Candidates must have prior experience with a highly automated and integrated claim adjudication system
Experience working with HealthRules Payer
Understanding of health insurance benefits administration in a self-funded environment
Preferred
Past Training Experience
Experience working at TPA
Experience with self-funded plans
An ideal candidate would be assigned to the Buffalo Office with ability to work from home.
If not in the Buffalo area, the opportunity can be remote.
Leadership Skills & Behaviors:
● Strategic Thinking – Knack for sorting through clutter to find the best route, often by pulling up from the current complexity to identify patterns that guide future direction and allow one to narrow the options and articulate the options from which others can work backward.
● Business Acumen – A keenness and quickness in understanding and dealing with a business situation (risks and opportunities) in a manner that is likely to lead to a good outcome. Critical to this is an ability to think beyond their own function.
