Manager, ITS Claims Operations

<strong>Working at Advantasure is more than a job &mdash; you&rsquo;re part of a team that is becoming the country&rsquo;s leading healthcare solutions provider.<br /></strong><br /><strong>A career at Advantasure means you&rsquo;ll be part of one of the most dynamic, diversified and innovative healthcare companies in the nation. You&rsquo;ll be helping our clients make their members healthier &mdash; and our communities a better place to call home.</strong>

Southfield, USA


<p class="p1"><strong>At Advantasure, we partner with healthcare clients to simplify their operations and accelerate their business success. Powered by our broad expertise and a comprehensive suite of product and service solutions, we help health plans effectively navigate the complexity of healthcare.</strong></p>

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Mid-level Manager

Competitive Compensation and Benefits Package

Overview: <br /> <p>The Manager, ITS Claims Operations is responsible for overall direction and execution of meeting client contractual obligations around the ITS Claims Adjudication life cycle, and Claim Adjustments activities ensuring the accuracy and timeliness of ITS claims processing for the BlueCard program. This role is also responsible for performing, developing, analyzing, and evaluating claims operational performance and processes and requires effectively leading and participating in discussions with Clients, Leadership Team, Providers, internal teams, and business process outsourcing vendors. <br /><br />The responsibilities include leading the Claim Operation area for People, Process, and Technology needs. This role is also responsible for managing all Plan to Plan activities as well as developing training materials for BlueSquared.&nbsp;The goal is to maintain the retention, membership, and service goals for the Medicare Advantage product line for the Advantasure organization.&nbsp; <br /><br />Additional responsibilities include maintaining effective customer service and relations with current clients and ensuring that corporate leadership team is informed of all activities. Responsible for analyzing, planning, organizing, budgeting, identifying equipment needs, and other functions that are required to maintain and operate an efficient department.<br /><strong><br /><br />WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards or remotely. 20% travel may be required as needed.</p>
Responsibilities: <br /> <ul> <li>Develop and implement an effective claim adjudication structure that meets all regulatory and client requirements.</li> <li>Ensure that the Life cycle of a claim is standard and allows for an Auto Adjudication rate that is at or better than industry averages</li> <li>Manage Claim SLAs with downstream vendors to ensure that Claim turnaround times are within Client and regulatory SLAs.</li> <li>Works toward reducing defects and improving the first pass rate of the claim adjudication life cycle.</li> <li>Identifies problems related to Provider file transmissions with clients, identify the cause and implement plans and actions to improve reject rates</li> <li>Manage a team of ITS Claims Specialists and other claim roles</li> <li>Approve and manage employee timesheets</li> <li>Performs and holds 1:1 and Team meetings on a regular and consistent basis</li> <li>Work with and coordinate with other Blue partners on Global Certification.</li> <li>Work with claims processor on testing and timelines of new Plan Connextion releases.</li> <li>Establish a mutual partnership with other ITS plans.&nbsp;</li> <li>Monitoring of ITS claim files uploaded in systems.</li> <li>Identify and report trends and issues detected and provide issue resolution in error processing and escalated issues.</li> <li>Support and participate in system testing and requirements gathering related to operational readiness updates based on system enhancements, CMS software releases, and as needed.</li> <li>Provide and implement quality and process improvement initiatives; assist in the creation and implementation of policies and procedures and workflows.</li> <li>Support all CMS and internal audit activities as needed.</li> <li>Develop and maintain all training materials related to BlueSquared activities</li> <li>Deliver standup training of BlueSquared materials to employees and vendors as needed</li> <li>Manage all aspects of Plan to Plan activities including developing scripts and desk level procedure documentation</li> <li>Develop all call scripts for Plan to Plan activities and draft all other needed collateral related to Plan to Plan processing</li> <li>Monitor Plan to Plan lines as needed for quality as well as incoming volume</li> <li>Knowledge of IKA system functionality in relation to claims</li> <li>Develop and manage IPP Scorecard</li> <li>Provide reporting on Plan to Plan metrics</li> <li>Serve as primary point of contact for ITS escalated issues</li> <li>Develops and improves workflows and business processes within area(s) to improve customer service, decrease operational costs, and improve overall quality.</li> <li>Identifies and/or analyzes business problems and devises procedures for solutions to the problems.</li> <li>Develops and maintains an effective working relationship with customers.</li> <li>Effectively leads projects/teams in order to produce desired results.</li> <li>Responsible for corporate communication of project results.</li> <li>Work with Human Resources to coordinate interviewing, hiring, and development of new hires to department</li> <li>Manage an effective communication process with all stakeholders, managers, and staff regarding results, key developments, recommendations, and industry data. Provide quarterly trends analysis to senior management (broken down by region).</li> </ul>
Requirements: <br /> <p><strong>EDUCATION:</strong></p> <ul> <li>Bachelor's Degree in Business Administration, Health Care Administration, or related field required.</li> </ul> <p><strong><br />EXPERIENCE:</strong></p> <ul> <li>Ten years experience in a health plan operations environment, including claims processing; with demonstrated technical experience that provides the necessary knowledge, skills, and abilities.&nbsp;</li> <li>Five years supervisory or leadership experience required.&nbsp;</li> </ul> <br /> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Knowledge of ITS claims processing.</li> <li>Excellent verbal and written communication and interpersonal skills.</li> <li>Strong analytical and critical thinking skills with high attention to detail.</li> <li>Must be able to be flexible in a fast pace environment and adaptable to change.</li> <li>Ability to work independently as well as with all levels of staff, leadership and external partners and vendors.</li> <li>Ability to effectively prioritize, coordinate and lead activities.</li> <li>Strong working knowledge of Microsoft office products.</li> <li>Demonstrated ability to process health care claims and to understand claim life cycle.</li> <li>Ability to problem solve and create solutions that can be implemented.</li> <li>Ability to be self-motivated and independent.</li> <li>Knowledge of health insurance industry operations, specifically claim adjudication procedures</li> </ul>