Manager Stop Loss Claims

Job ID: J132162
Company: HM Life Insurance Company
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Dec 7, 2018

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Description

I.    GENERAL OVERVIEW:  
This position is responsible for leading a team of supervisors who are responsible for day to day stop loss operations. This position is also responsible for overseeing all specific stop loss claims and related customer service activities, in multiple office locations as well as work from home staff.  It oversees TPA education activities nationally, including notice requirements, discounting guidelines and timely monthly aggregate report submission. 
Additionally it oversees staffing, performance and training of departmental employees including coaching, consulting and mentoring supervisory staff on complex issues related to the handling of any specific stop loss claims and or customer service activities.


II.    ESSENTIAL RESPONSIBILITIES:  
1.    Overseeing all specific stop loss claims and related customer service activities, in multiple office locations as well as work from home staff.  Oversee all claim and customer service activities ensuring that corporate goals for claim turnaround time, service and quality are met or exceeded.  Ensure proper Cost Containment techniques have been employed at the TPA level, in support of the corporate loss ratio goals.  This includes, but is not limited to, verification that PPO discounts exist or alternate cost containment methods are 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.
2.    Overseeing TPA education activities nationally, including notice requirements, discounting guidelines and timely monthly aggregate report submission.   Ensure all TPAs have been educated regarding HMIG stop loss claim and cost containment expectations as well as what HMIG value added services are available to the TPA. This includes any related training, internal and external, and requires periodic travel nationally for meetings related to claim and cost containment.   Participate in the TPA review process and work closely with the national sales staff and underwriting staff to ensure that on-site operational reviews are conducted when appropriate and in a timely manner. 
3.    Overseeing staffing, performance and training of departmental employees including coaching, consulting and mentoring supervisory staff on complex issues related to the handling of any specific stop loss claims and or customer service activities.  Conduct periodic review of specific stop loss claims and service activity performance as contrasted with the strategic objectives for the team.  Address deficiencies and/or weaknesses and coordinate corrective action which may involve changes to processes, systems, TPA Program/Education process and requires ongoing communication with HMIG underwriting personnel and field sales representatives as well as contracted vendors.
•    Ensure effective and efficient staffing for all levels within the department.
•    Oversee assignments and workload balancing.
•    Provide ongoing training and coaching to supervisory staff to include: (a) Analyzing complex claim data, (b) Assessing business processes and coordinating any resulting changes, (c) Assessing systems issues and accompanying resolution, (d) Problem solving and decision making, and (e) Workload balancing and Inventory Management.
4.    Communicating effectively with all levels of the organization and senior management.   Identify and articulate problems to department management and/or project team members.  Interacts with other departments 
5.    Promoting a culture of performance excellence departmentally. Enhancing job skills through available tools, training/certifications.  Participating in process and operational improvements on an ongoing basis.  Building and maintaining effective relationships throughout the organization in support of Performance Excellence
6.    Other duties as assigned or requested.


III. QUALIFICATIONS:
Minimum

  • High School Diploma/GED
  • 5 years experience managing specific stop loss claims with inventory management accountability
  • 5 years experience handling first dollar medical claims 
  • Prior experience managing people

Preferred

  • Bachelors Degree in a business related field
  • Prior experience managing in an insurance operations claim production environment
  • Prior experience managing supervisors

Knowledge, Skills and Abilities
•    Proficiency with Word and Excel
•    Excellent organizational skills
•    Excellent communication skills
•    Excellent business writing skills
•    High standard of professional ethical conduct
•    Ability to maintain confidential information

IV. SCOPE OF RESPONSIBILITY:
Does this role supervise/manage other employees?   Yes          
If yes, indicate the number of direct reports:  3


V. WORK ENVIRONMENT:
Is Travel Required?    Yes  

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)
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For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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