Highmark Health Supervisor Performance Measurement Reporting in Camp Hill, Pennsylvania
Job Description :
I. GENERAL OVERVIEW:
The Supervisor Performance Measurement Reporting provides day-to-day oversight and supervision of sampling, auditing, and reporting activities within Performance Measurement and Reporting (PMR) operations. The scope of responsibilities is broad based, covering claim, customer service and enrollment transactions. Specifically, this position will mainly focus on claim audits falling under Performance Guarantee and BCBSA audit Programs. In addition the position is responsible for supervising all facets of the audit function, which includes, but is not limited to: promoting quality within the company; interpreting and applying quality program requirements and mandates and ensuring compliance; monitoring remediation; publishing performance results (internally and externally); and leading or supporting audit system project activity. This position also ensures an effective Audit-to-Operations feedback loop and is responsible for administrative duties such as recruiting, training and developing of staff, mentoring and coaching, assessing performance and developmental needs, as well as contributing to the development of effective strategic and succession plans.
II. ESSENTIAL RESPONSIBILITIES:
Ensure an effective Audit-to-Operations feedback loop, by providing specific and detailed audit results to management, thereby facilitating action by Operation’s in addressing/resolving any control or workflow weaknesses.
Supervise PMR operations—oversees all activities related to day-to-day audit operations, which includes designing and maintaining statistical sampling plans, assigning and monitoring staff work, researching and interpreting audit requirements, resolving error disputes, and modifying audit methods, procedures, processes and protocols to accommodate changes in Operations and corporate technologies, etc.
BlueStar system projects—this is a technical component of the job that involves leading or supporting system projects and activities related to the maintenance or development of Bluestar, relative to primary areas of responsibility. This includes developing project plans, requirements and specifications, designing formats, panels and data views, researching and resolving problems, requesting program or table changes or updates and conducting user testing, etc.
Reporting—includes the compilation, tracking, trending, analysis and reporting of performance results.
Staff development—this aspect of the job requires training, coaching and mentoring staff and participating in the succession planning process, as well as performing administrative duties such as recruiting, conducting performance reviews, approving and managing time and attendance, holding staff meetings, managing system accesses, etc.
Other duties as assigned or requested.
High School Diploma/GED
8 or more years of experience in auditing, quality function or operations management
Bachelor’s degree in a business related curriculum
5 or more years of experience in auditing, quality control, or operations management
Knowledge, Skills and Abilities
Broad knowledge of company core operations with specific knowledge of claim, customer service and enrollment functions.
Intermediate-level project management experience.
Specific knowledge of claim adjudication, customer service, and enrollment processes and systems, as well as coding and billing protocols (ICD, CPT), reimbursement methodologies (Per Diem, Tier, PMC, DRG, UCR, etc.), medical policies and procedures, and other resource tools used by the company to support core operations.
Advanced knowledge of PMR process functionality and relevant operational interrelationships.
Advanced-level skills in using standard desktop applications such as Lotus Notes, Excel, Word, etc.
Advanced-level knowledge of BlueStar system.
Advanced understanding of quality measurement terminology and concepts as applied to PMR operations.
Intermediate-level technical skills, as defined broadly in terms of abilities to: analyze data; research, interpret and assimilate data and information; identify and understand cause-and-effect relationships; define and frame issues; resolve problems; utilize IS tools; apply statistical sampling concepts and methods, etc.
Excellent productivity skills, as defined broadly in terms of: abilities to: meet deadlines; make decisions and judgments; utilize resources; produce quality work; manage project activities, etc.
Excellent management skills, as defined broadly in terms of abilities to: evaluate work of others, provide career and advancement coaching; delegate work assignments, provide leadership, etc.
Solid communication and interpersonal skills, as defined broadly in terms of abilities to: communicate effectively; manage conflicts; use diplomacy; negotiate resolutions; work in a team environment, etc.
Strong personal characteristics, as defined broadly in terms of attitude, corporation, creativity, dedication, dependability, ethical behavior, flexibility, initiative, professionalism, etc.
IV. SCOPE OF RESPONSIBILITY: (People Management Responsibility)
Does this role supervise/manage other employees? Yes
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