Highmark Health VP, Operations - Gateway Health Plan in Pittsburgh, Pennsylvania
This job is responsible for the Operations Division which is responsible for Claims and Enrollment establishing and re-engineering of and continued improvement of internal business operational processes, as well as the detail design, maintenance, and improvement/re-engineering of business structure and business work flow processes. Oversees operations of the following departments: Claims and Membership Administration. Oversees operations of Claims Processing and activities performed through an outsourcing relationship with DST, as well as insourced claims for WV and DE. Directs intra and interdepartmental activities related to the re-engineering of and continued improvement of internal business operational processes, as well as the management of the development, testing and implementation of system enhancements, new software releases, and interfaces between the Managed Health Care system and other systems. Responsible for the detail design, maintenance and improvement/reengineering of business structure and business work flow processes. Serves as a consultant with Gateway Health Plan on matters relating to decision support, data analysis and Managed Health Care System functionality, assisting in optimizing relations with providers through implementation of improved claims processing and electronic and web-based servicing tools.
Accountable for penalties assessed by state agencies for failure to meet timely claims payment standards. An active participant in the development and execution of Gateway Health Plan’s strategic and tactical plans, to include but not limited to planning and budgeting decisions, normal personnel and administrative duties. Routinely identifies trends and informs COO of sensitive issues and/or problem areas in the Plan’s dealing with providers, and recommends and implements corrective action.
Serves as a consultant with Gateway Health Plan on matters relating to decision support, data analysis and Managed Health Care System functionality, assisting in optimizing relations with providers through implementation of improved claims processing and electronic and web-based servicing tools. Works closely with Provider Relations in educating providers regarding Gateway Health Plan’s procedures and programs, and monitoring claims issues to ensure providers are paid appropriately..
Oversees Claims Processing and Membership Departments
The department is accountable for accurate: Check runs, enrollment files, quality, ID cards, State/Federal claims and enrollment report submissions and to ensure timely claims payment and membership processing activities
Department also coordinates and performs software release testing, training and implementation with in-house and outsourcers.
Works closely with the Director of Claims and Enrollment to administer claims processing activities via an outsourcer or insourced at Gateway through involvement in the development of claims rules and processes to ensure proper payment to providers and monitoring compliance with performance standards. Large annual claim volumes for seven states, which is subject to stringent penalties for untimely claims processing. Oversees claim review activities performed in house and at the outsourcer, which includes the maintenance of the ClaimCheck software and processing of high-dollar claims, review of claims suspended for fee or benefit issues, research of provider requests, research of provider and member claim appeals and coordinate subrogation activities.
Oversee Membership Administration Department
Education, Experience, Licenses/Certifications
Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job.
Bachelor’s degree in or equivalent training in Business, Health Management or relevant field.
7-10 years of experience in managed care operations in a senior management role.
Master’s degree in Business/Health Management or relevant field
IS-related positions – 5 years
Provider and contracting – 5 years
Knowledge, Skills and Abilities
Documented successful work experience demonstrating strong interpersonal skills, to include but not limited to, effectively working with technical personnel and executive management.
•Documented successful work experience demonstrating excellence in:
Organization and planning
Demonstrated excellent verbal and written communication skills with an emphasis on negotiations.
Demonstrated successful experience demonstrating effective motivational and leadership skills.
Demonstrated business knowledge of: benefit structures, claims and membership processing, contracting and other financial arrangement and objectives.
Demonstrated basic knowledge of: medical terminology, procedure coding, electronic claims submissions, coordination of benefits, and Decision Support Systems.
Demonstrated thorough working knowledge of processing systems and core claims and administration systems, as well as web-enabling and electronic data transfers with subcontractors.
Demonstrated strong, working understanding of Total Quality Management techniques, NCQA standards, HEDIS reporting and medical management processes
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No □ Yes ■
Is Travel Required?
No □ Yes ■
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity