Operations Manager (08-10 years)
Calibrated Healthcare Network (CHN) is a decade old healthcare firm that provides a suite of services across three service lines; Healthcare Administration, Medical Management, and Population Health Management. Calibrated’s unique Operating Model combines acclaimed clinical/operational leadership with a Hybrid Global Footprint to deliver distinctive value to clients. Our extensive and proven expertise in managed care sets us apart; managing over 11 million lives in over 8 states, with clients that include the dominant national and regional players in the industry
Manages, plans and oversees operations staff to ensure the accurate and timely processing of SLAs in accordance with vendor contracts, fee schedules requirements and established departmental and governmental guidelines. This position is responsible for Claim development, EDI, Benefits, Eligibility, Utilization Management, Jurisdiction resolution, as well as other health insurance, duplicate claims, and manual fee processing. This role oversees claims processing vendors, reviewing and adjudicating claims based on provider and health plan contractual agreements and claims processing guidelines.
Duties and Responsibilities
Leadership & Development
- Hire, train, retrain and maintain a qualified staff of employees. This includes coaching and developing skills of staff members and conducting performance evaluations
- Demonstrated ability to work independently and establish and accomplish team goals. Investigative, decision-making, problem solving, interpersonal, and organizational skills.
- Oversees a broad scope of professional management activities related to the day-to-day management of the operation.
- Serve as regulatory compliance agent
- Serve as departmental contact in dealing with other departments on cross-department projects and/or initiatives as directed by management
- Assist with development and implementation of measurement systems to monitor the effectiveness of business process improvement initiatives and the impact on financial performance metrics.
- Assists the department Executive in the day-to-day management operation which includes reviewing adequate staffing with properly-trained personnel, monitoring of operational productivity, accountability for quality and quantity of work, and analyzing and making recommendations to directors and managers in managing their teams.
- Responsible for maintaining all departmental policies and procedures, ensuring that they are reflective of the current process and staff have signed-off and understanding to carry out day- to-day operations
- Track production, error trending, develop workflow procedures and take corrective action on claim system issues.
- Provides direction and training on extensive claim research, problem analysis and claim payments.
- Evaluates teams on a regular basis to ensure positions within the teams are appropriate and operating to achieve efficient productivity. Make recommendations for changes as necessary to achieve appropriate staffing levels to meet cost of servicing goals.
- Tracks and monitors daily claim activity for appropriate case loading and assignment of new matters, escalation and reassignment of matters, and monitoring closure rates to ensure appropriate staff loading.
- Possesses a thorough understanding of client environment and has the ability to obtain group consensus with follow up implementation through staff.
- Collaborates and provides direction to managers to enhance technology and service delivery to include analyzing, proposing, testing, implementing, training, maintaining and monitoring in order to continuously improve customer satisfaction levels, operational effectiveness and cost efficiencies
- Interfaces with colleagues at all levels within the organization, external customers, and carriers to ensure maximum efficiency, and problem resolution.
- Establishes data benchmarks, implement data driven decision making and identify ways to leverage data and information to identify trends to improve operational processes and results.
Education and Experience
- Bachelor’s Degree in Business Administration, Health Care or another related field
- 8+ years of experience in US Healthcare that directly aligns with the specific responsibilities for this position
- 3+ years of managerial, supervisory, and/or demonstrated leadership experience including influencing senior management/critical stakeholders experience
- Strong technical skills to include Access, Excel, Imaging Systems
- Proven analytical skills to show process improvement abilities
- Knowledge of electronic claim filing formats preferred
- Must have a thorough understanding of claims operations, including, but not limited to, prior roles as adjuster/examiner, claims operations, claims manager or equivalent.
- Ability to independently formulate solutions and employs and examines all resources available to implement solutions.
- Demonstrated ability to function effectively as a team-oriented leader, able to work independently but also lead cross-functionally.
- Proven project and time management skills; must be resourceful in developing alternative solutions and meeting deadlines in a real time, fast paced environment.
- Knowledge and/or experience implementing Six Sigma processes a plus
- Demonstrated use of logic and creativity in decision making.
- Understanding of Healthcare Compliance (HMO)