Job ID: J114973
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Feb 1, 2018
I. GENERAL OVERVIEW:
The Director of Configuration & Operations is responsible for leading system configuration for client set-up and maintenance for all government product business, as well as partner plan business processing. Accountable for the financial accuracy and service responsiveness related to benefit application and client administration that may support claims processing, enrollment processing, prescription drug processing, billing, and creation of benefit booklets and contacts. Responsible for proactive issue resolution, and quality control associated with client administration and benefit operations. Accountable for the identification of enhancements and expanded capabilities of major enterprise systems supporting client administration. Ensure the implementation and adherence of government regulations, corporate policy mandates, corrective action plans, and process improvement initiatives. Establish overall strategic and tactical business and operational plan for assigned areas. This position is responsible for motivating and cultivating a team to provide excellent service allowing for a consumer centric approach balanced with a cost competitive structure to achieve opportunities for additional business. Directs the technology and operations strategy related to claims processing, benefits administration, and reporting. Assess systems, processes and people and make recommendations. Define business requirements for software programs used to load, maintain, or transmit claims and encounter information. Responsible for delegation oversight for subcontractors as well as communicating strategic direction and business requirements related to Medicare, Medicaid and partner plan processing Review, document, and communicate software requirements to various vendors to ensure that both internal and external systems perform as required. Work with multiple external entities to ensure that the vendor’s data is accurate and that the applicable software is performing as required. Provide oversight and direction of the outsourced application development for each product line.
II. ESSENTIAL RESPONSIBILITIES:
1. Provide leadership and oversight of management for client administration and product business processing on system platforms service operations. Participate in the formulation and execution of the division’s service operations strategy and vision.
2. Direct efforts to identify and make operational strategic initiatives that impact and improve operational capabilities related to benefit application, product development and client administration. Establish, monitor and work with team to continuously improve on all aspects of operations.
3. Resolve high-impact operational and processing problems and consequence (e.g., financial, reputation, and customer service) and adhere to corporate and contractual performance measurements and standards, as well as comply with federal and state mandates related to product, administration and claims processing. Ensure all operational processes are in compliance with established quality standards, government and industry regulations, and client requirements.
(If required: CMS Reporting) Accountable for CMS required reporting and operating a CMS regulated business in compliance with Medicare C&D regulations.
4. Work closely with other management areas to ensure operational consistency within the organization and all lines of business. Provides direction, feedback and final approval on the setup of various systems to allow for accurate reporting and reconciliation. Manage the platform configuration with accountability for financial accuracy, proactive issue resolution and quality control associated with the operations on an annual basis.
5. Ensure high quality employees are hired for team and provide coaching, mentoring, and leadership to direct reports and team.
6. Provide significant input and direction to the development of future operational capabilities by evaluating, investigating and recommending newly defined systems, process and techniques.
7. Direct and ensure that all budget guidelines are met.
8. Responsible for all aspects of the systems and processes to operate Plan Partner's business as well the
membership data conversion, coordination with corporate systems, compliance for government required
mailings, Service Level Agreements adherence and reporting, managing staffing in accordance with pricing model provided
to Plan Partner and regulatory compliance.
9. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience
• Bachelor’s Degree or 7+ years related experience
• Seven (7) years of experience in large operations environment
• Seven (7) years of experience with insurance products principles, industry practices, and processes
• Master’s Degree
• Five (5) years of experience in claims processing with insurance product knowledge
• Five (5) years of experience in workforce development and resource management
• Three (3) years of experience marketing or selling services for operational capabilities
• Three (3) years of experience with project management
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