Lead Managed Care Analyst

Job ID: J130147
Company: HM Life Insurance Company
Location: Miami, FL, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Oct 2, 2018

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Description

I.    GENERAL OVERVIEW:  
This position is responsible for reviewing, evaluating and processing various Excess Risk and Reinsurance Claims.  It is responsible for the conversation of positive client relationships, education and analysis of client claim losses as well as analysis of current issues regarding client activities with dissemination of this information to the HM Insurance Group management staff.


II.    ESSENTIAL RESPONSIBILITIES:  
1. This position displays effective communication skills while performing the following functions:
•    Providing counseling to clients and assisting with client service programs.
•    Interaction with internal departments (Underwriting, Managed Care, Accounting etc).
2. Claims Analysis
•    Process daily incoming Stop Loss claims
•    Monitor, review and analyze various potential claims with emphasis on controlling losses through effective managed care
•    Frequent overnight travel nationally to assist Manager with performing client performance evaluations to assess the accuracy of client reports submitted to HM Insurance Group, efficiency of claim operations, and adequacy of systems and procedures.
•    Evaluate various claims submitted by TPAs on behalf of self-funded clients for compliance with the following:
o    underlying policy provisions
o    federal and state regulatory guidelines
o    industry standards.  
3. Client Interaction
•    Approve claim payments on behalf of multiple clients
•    Provide client counseling and support services
•    Assist in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with HM Insurance Group.

4. Other duties as assigned or requested.


III. QUALIFICATIONS:
Minimum:
•    High School Diploma/GED 
•    10-15 years of related progress experience in the area of specialization including experience in leading projects of varying size and complexity. Grandfathered experience requirements effective August 2016.
•    Prior experience handling Specific  Stop Loss claims
•    Prior experience with Medical Terminology


Preferred:
•    Bachelor’s Degree
•    Prior experience in insurance operations with inventory  management experience


Knowledge, Skills and Abilities:
•    Ability to communicate concise accurate information effectively
•    Organization
•    Ability to manage time effectively
•    Ability to work independently
•    Problem Solving and analytical skills

IV. SCOPE OF RESPONSIBILITY  
Does this role supervise/manage other employees?  Yes 
 


V. WORK ENVIRONMENT
Is Travel Required?
No  
 

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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