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General Summary of Position
The Manager of Health Plan Operations has responsibility for providing leadership and management of the BPAAS vendor in the areas of claims, enrollment, customer service and payment integrity related services, including processing, auditing, research, and resolution, reporting and process improvement.
The Manager reports directly to the Vice President of Operations and partners with other departmental managers and external vendors on all strategic and tactical matters as they relate to claims adjudication and payment, enrollment, customer service and payment integrity.
Primary Duties and Responsibilities
Ensures systems are configured appropriately for accurate and timely payment by overseeing the gathering of business requirements, performing UAT testing and post validation functions.Collaborates with multiple departments to identify root cause of issues impacting Operations and partner with the appropriate vendor(s) for timely resolution.Provides ongoing oversight of BPAAS vendor management performance, works as the point of contact between MFC and contracted vendors.Develops auditing concepts, queries and reports to validate claims adjudication and payment.Oversees payment integrity related to vendors including escalations, invoice validation/payment and implementation. Develops and contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Oversees the selecting, training, orienting, and evaluating of staff. Develops standards of performance, evaluates performance, and conducts performance management coaching. Initiates or makes recommendation for personnel actions. Maintains ongoing communication with Associate to track progress on projects and responsibilities, provide feedback, discuss new developments, and assist in problems solving.
Minimum Qualifications
Education
- Bachelor's degree required and
- Equivalent work experience required
Experience
- 5-7 years In health plan or managed care operations required
Licenses and Certifications
- CPC (Certified Professional Coder) certification preferred
Knowledge, Skills, and Abilities
- Ability to create reports in SQL and analyze large sets of complex data.
- Knowledge of all aspects of operations including claims auditing, coding, enrollment and customer service functions.
- Strong decision making ability and proficiency with Microsoft Office suite.
- Excellent verbal and written communication skills.
This position has a hiring range of $80,995 - $152,027
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MedStar Health
Jan 04, 2025