Description
Director, Claims & Customer Service ……..................................$70K-$80K
Responsible for the overall direction, coordination and evaluation of the Claims and Customer Service areas. Involves “hands-on" daily interaction with Medical/Pharmacy and Claims Customer Service Agents, and other relevant departments, particularly Clinical Services and IT. Responsible for delivery of quality service to members, providers and pharmacies that exceeds customers’ expectations, Company standards and contract obligations.
*Plans, organizes and manages Customer Service and Claims functions. Works “on the floor" and coaches team leaders/area managers in the supervision of Medical/Pharmacy and Claims Customer Service Agent activities.
*Drives performance by ensuring all employees are trained, work is completed accurately, timely, and meets company and contract standards.
*Monitors and tracks individual, team and call center performance against established productivity and quality metrics, including regular audits assessing department performance. Identifies and acts on both positive and negative performance trends to ensure attainment of goals.
*Monitors phone calls to observe agent demeanor, technical accuracy, and conformity to HIPAA, URAC and Company standards. Addresses agent performance as needed.
*Monitors work queues, prioritizes incoming authorizations and effectively delegates tasks to team leaders/area managers to ensure company standards and contract obligations are met.
*Handles complex customer issues escalated by agents and team leads. Coaches agents and team leads in troubleshooting routine as well as difficult customer issues.
*Participates in daily, weekly and ad hoc cross-functional meetings to discuss and resolve operational and technical issues.
*Oversees day-to-day claims operations, including claims evaluation, adjudication and customer service in accordance with contract and Company quality and production standards.
*Reviews Claim audits for completeness, accuracy of information and compliance with company policies, standards and procedures. Resolves any issues or directs claim to team lead/area manager for resolution prior to payment.
*Recommends changes to workflow, procedures or policies and ensures that all Customer Service and Claims employees are fully informed, understand and implement changes.
*Identifies, leads, develops and organizes training, re-training and cross-training of team members and new employees as appropriate and in coordination Human Resources and IT Project Managers.
*Prepares and presents a variety of management reports, including explanation of variances, significant trends, and recommendations for change or resolution. Keeps COO adequately informed of department issues, trends, challenges, and problem identification/resolution.
*Ensures service compliance with client performance guarantees, and regulatory or accreditation standards.
*Participates in sales presentations, demonstrations, and new client implementations as needed, to ensure smooth and timely transition of new business.
*Follows and ensures team follows HIPAA and URAC protocols when discussing or accessing protected health information.
*Responsible for direct supervision of Team Leaders and Managers, and indirect supervision of Medical/ Pharmacy and Claims Customer Agents.
*Carries out supervisory responsibilities in accordance with Company policies and applicable laws.
*Responsibilities including interviewing, participating in hiring decisions, and training employees; planning, assigning, and directing work; appraising performance; addressing and resolving problems.
Please send your resume to [Click Here to Email Your Resumé]
Requirements
*Bachelor’s degree in a business-related subject or equivalent experience.
*At least 5 years Customer Service experience managing a Claims and Customer Service unit with a healthcare payor, delegated vendor, or TPA, supervising a team of agents.
*A minimum of 3 years experience in a training role, capable of documentation, training delivery, customer care performance management, and call management proficiency.
*Strong technology background interfacing with IT personnel. MS Office and database knowledge required.
*Knowledge of DRG/ICD-9, NDC/GPI, CPT/HCPCS, and RVU coding.
*Working knowledge of current health insurance product options, including HMO, PPO, EPO, high deductible plans, copay/coinsurance variations, and HRA’s/HSA’s.
*Expertise in claims adjudication, including interface with payors with or without delegation, eligibility and benefit determination, and member copay/coinsurance allowances.
*Working knowledge of electronic commerce, including EDI submission and payment of provider claims, EDI submission to payors, EFT, transmission of forms, and web portal interface for providers and members.
*Thorough HIPAA knowledge.
*Knowledge of NCQA Guidelines, URAC Accreditation and Utilization Management desirable.
*Experience with pharmacy benefit management, disease management, care management or the pharmaceutical industry desirable.
*Previous experience with telecommunications in a call center environment preferred.
Location: White Plains, New York
Please visit our website at classicwestchester.com
