Manager Operations Quality Assurance

Job ID: J122497
Company: HM Life Insurance Company
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 22, 2018

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Description

JOB SUMMARY

This job manages internal Quality Assurance functions, including stop loss reviewer and examiner claim audits, nurse audits, cost containment, stop loss underwriting and other various quality audits. Manages the claim audits of external MGU partners and TPA partners. 

ESSENTIAL RESPONSIBILITIES

  • Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.  Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
  • Manage the development, design, and ongoing operation of all internal Quality Assurance functions for all stop loss activities, including claims, nurse, cost containment, and stop loss underwriting. Provide management with monthly quality results identifying the strengths and weaknesses of the functional area and provide recommendations for improvements/changes needed to achieve Corporate Strategic Objectives.
  • Oversee the audit programs for MGU partners and TPA partners, ensuring that partner activity is in compliance with HMIG corporate practices and procedures. Make recommendations as needed, with appropriate follow through on all recommendations. Address deficiencies and/or weaknesses and coordinate corrective action which may involve changes to processes, systems, and requires ongoing communication with internal MGU Relations department, sales offices as well as the MGU and TPA partners.
  • Conduct audits to ensure proper internal Cost Containment procedures are followed by both the Claims staff and the Clinical/Cost Containment staff, including but not limited to: verification that PPO discounts exist or alternate cost containment methods were employed, identification of potential subrogation opportunities with appropriate internal action, identification and proper handling of other issues that impact stop loss claims payment and directly impact loss ratios with appropriate internal action.                
  • Conduct audits to ensure all specific stop loss claims processed by HM Insurance Group are processed in accordance with the terms of the applicable Summary Plan Description and Stop Loss Policy.
  • Other duties as assigned or requested


EDUCATION

Required

  • Bachelor's Degree in Business Administration/Management

Substitutions

  • None

Preferred

  • None

EXPERIENCE

Required

  • 5 - 7 years in Claims Administration

To include

  • 3 - 5 years in Management
  • 0 - 1 year in Audit

Preferred

  • 0 - 1 year in the Insurance Industry

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • Communication

Language (Other than English)

None 

Travel Required

0%  - 25%

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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