Job ID: J131377
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Sep 12, 2018
This job is responsible for the Operations Division which is responsible for Claims and Enrollment establishing and re-engineering of and continued improvement of internal business operational processes, as well as the detail design, maintenance, and improvement/re-engineering of business structure and business work flow processes. Oversees operations of the following departments: Claims and Membership Administration. Oversees operations of Claims Processing and activities performed through an outsourcing relationship with DST, as well as insourced claims for WV and DE. Directs intra and interdepartmental activities related to the re-engineering of and continued improvement of internal business operational processes, as well as the management of the development, testing and implementation of system enhancements, new software releases, and interfaces between the Managed Health Care system and other systems. Responsible for the detail design, maintenance and improvement/reengineering of business structure and business work flow processes. Serves as a consultant with Gateway Health Plan on matters relating to decision support, data analysis and Managed Health Care System functionality, assisting in optimizing relations with providers through implementation of improved claims processing and electronic and web-based servicing tools.
Accountable for penalties assessed by state agencies for failure to meet timely claims payment standards. An active participant in the development and execution of Gateway Health Plan’s strategic and tactical plans, to include but not limited to planning and budgeting decisions, normal personnel and administrative duties. Routinely identifies trends and informs COO of sensitive issues and/or problem areas in the Plan’s dealing with providers, and recommends and implements corrective action.
Education, Experience, Licenses/Certifications
Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job.
Knowledge, Skills and Abilities
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No □ Yes ■
Is Travel Required?
No □ Yes ■
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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