Job Summary:

• Work with Claims Upper Management to define and prioritize the release content for Claims Management System and other 3rd party applications.
• Defining objectives, goals, success metrics, cross-functional alignment, implementation, and governance
• Shape and identify priorities and partnership strategies while working closely with Claims as well as ecosystem partners
• Build and maintain relationships with business and product stakeholders to develop and accelerate strategic projects
• Lead and participate in quarterly business reviews with partners and offer a strategic and analytical perspective of the partnership, identifying areas for improvement and growth
• Oversee and coordinate the Claims Department’s Innovation Efforts
• Participate in the Claims Innovation Task force to identify opportunities that positively impact customers and associates
• Monitors and evaluates one or more units to ensure the accurate and timely processing of claims. 
• Develops effective claims processing standards that incorporate the use of automated claims systems and other technology solutions.
• Ensures compliance with all applicable laws, regulations, and contract requirements while meeting performance expectations.
• Monitors all reports and quality audits to ensure the efficient operation of the department. 

Skills on Resume: 

• Project Management (Hard Skills)
• Stakeholder Engagement (Soft Skills)
• Strategic Planning (Hard Skills)
• Analytical Skills (Hard Skills)
• Innovation Management (Hard Skills)
• Process Improvement (Hard Skills)
• Compliance Management (Hard Skills)
• Quality Assurance (Hard Skills)

Job Summary:

• Lead and support key business plan activities by actively participating in divisional and cooperate initiatives, projects, CSRs, audits and workgroups.
• Drive the delivery of goals set forth by the division through monitoring and oversight of Performance Metrics (First Pass Rate, Production, Quality/Accuracy, Five Star Rating, First Call Resolution and Timeliness measures, etc.) while meeting CMS requirements.
• Ensure the development of team members by assessing training needs as well as actively supporting the continuous learning and development of staff.
• Provide effective communication of project activities to internal and external constituents.
• Ensure execution of all Medicare Advantage Claims testing and testing resources providing guidance and support.
• Enhance and maintain operational dashboard reporting that demonstrates trends, strengths and areas of potential compliance risk.
• Establish partnerships throughout BCBSMA and externally to meet strategic planning goals and business needs.
• Manage claims vendor relationship and performance against agreed upon standards, and document variance.
• Track, monitor and report on critical unit deliverables ensuring they are met.
• Ensure staff is informed and kept up to date on key information and business changes needed to perform job requirements.
• Introduce and manage best workflow and business practices that will enhance daily processing.
• Acquiring and retaining talent through effective recruiting, onboarding, management, and succession planning.
• Regularly meet with team members to provide performance and development feedback, coaching and recognition

Skills on Resume: 

• Strategic Leadership and Oversight (Soft Skills)
• Performance Management (Hard Skills)
• Training and Development (Soft Skills)
• Project Communication (Soft Skills)
• Claims Testing and Compliance (Hard Skills)
• Data Analysis and Reporting (Hard Skills)
• Stakeholder Engagement (Soft Skills)
• Vendor and Performance Management (Hard Skills)

Job Summary:

• Manage the claims inventory
• Produce and review reports at predetermine frequencies
• Review and monitor productivity and quality of the Claims Operations Department
• Address general questions and concerns received from internal and external stakeholders
• Create, review and train staff on departmental policies and procedures
• Lead and or participate in various cross-functional committees and workgroups, representing Claims Operations
• Perform time and attendance and overall performance management of the Claims Operations staff
• Oversee status of production in the Claims Operations Department to ensure productivity standards are met
• Resolve processing and/or system issues within the Claims Operations Department
• Analyze the impact of new implementations impacting Claims Operations and allocate resources appropriately
• Assist in preparation of annual operating budget
• Drive change initiatives to address business needs
• Collaborate with the Claims Audit & Compliance Manager on all quality and compliance matters

Skills on Resume: 

• Inventory Management (Hard Skills)
• Report Production and Review (Hard Skills)
• Quality and Productivity Monitoring (Hard Skills)
• Stakeholder Communication (Soft Skills)
• Policy and Procedure Management (Hard Skills)
• Committee Participation (Soft Skills)
• Performance Management (Hard Skills)
• Issue Resolution and Analysis (Hard Skills)

Job Summary:

• Supporting the Claims Operations Manager with project work.
• Working with finance team on a regular basis to ensure that cross-department goals are met in respect to allocated cash and audit.
• Working with ceded reinsurance team to ensure that cross-department goals to maximise recoveries from the ceded reinsurance programme are met.
• Work with reporting teams, offshore processing team and finance to ensure that Lloyd’s Europe Part VII reporting is timely and accurate.
• Using reporting systems to monitor and assess performance against Lloyd’s standards.
• Contribute to change projects related to London Market reform.
• Understand and troubleshoot bureau message issues for Lloyd’s SCMs and USMs.
• Support the claims teams in understanding and troubleshooting bordereaux processing issues.
• Ensure compliance with all statutory and internal Sarbanes-Oxley control requirements relating to claims handling.
• Draft update reports for the Risk Committee and Board.
• Contribute to technology projects.
• Continue to arrange for onshore work to be documented and moved offshore.
• Monitor performance and supervise staff.

Skills on Resume: 

• Project Management (Hard Skills)
• Financial Oversight (Hard Skills)
• Reinsurance Management (Hard Skills)
• Regulatory Reporting (Hard Skills)
• Performance Monitoring (Hard Skills)
• Change Management (Soft Skills)
• Technical Troubleshooting (Hard Skills)
• Compliance Management (Hard Skills)

Job Summary:

• Responsible for the administration & management of operational programs
• Proficiency in Eligibility, Enrollment, Provider & Member Services and Claims processing
• Oversees timely and accurate processing of claims in compliance with regulatory agencies and organizational expectations
• Oversees effective handling of provider inquires telephonically and/or electronically and prompt resolution with the highest level of customer service
• Oversee consistent auditing of claims processing results and appropriate feedback as necessary, to ensure complete, timely and accurate encounter reporting to Federal and State agencies
• Develop solutions and processes for efficient and effective health plan operations
• Ensures proper training for new and current staff.
• Maintains a high level of customer service with all internal and external customers. 
• Interacts regularly with internal departments for planning, training, and management purposes.
• Handle performance management activities including year-end performance appraisals, performance calibrations and compensation planning.
• Promote a culture of well-being, empower good decision making and leverage the power of diversity, equity and inclusion.
• Collaborate with peers to meet Key Performance Indicators and develop strategic initiatives to consistently improve throughout the business.

Skills on Resume: 

• Operational Program Administration (Hard Skills)
• Claims Processing Expertise (Hard Skills)
• Customer Service Management (Hard Skills)
• Quality Assurance and Auditing (Hard Skills)
• Process Improvement (Hard Skills)
• Training and Development (Hard Skills)
• Performance Management (Hard Skills)
• Cross-functional Collaboration (Soft Skills)

Job Summary:

• Develop, implement, and maintain a claims strategic roadmap for the evolution of PIB claims excellence, with a focus on customer service
• Building, developing and reporting a data and analytical claims reporting model
• Engaging with the PIB trading divisions to bring to life a clear and consistent claims proposition based upon the customers and business needs
• Advocate and drive continuous improvement
• Responsibility for the implementation and reporting of claims quality assurance and peer review
• Driving compliance and measurement against internal controls and industry standards
• Liaising with external parties, such as insurers, lawyers, loss adjusters, & TPAs
• Preparation and presentation of claims data for monthly and quarterly reporting
• Working alongside the Group Head of Claims and Regional Claims Managers to managing resource capacity
• Assisting with or assuming full responsibility for claims projects including horizon planning
• Supporting performance across the PIB Group

Skills on Resume: 

• Claims Strategic Roadmap Development (Hard Skills)
• Data and Analytical Claims Reporting (Hard Skills)
• Stakeholder Engagement (Soft Skills)
• Continuous Improvement (Hard Skills)
• Claims Quality Assurance (Hard Skills)
• Compliance and Internal Controls (Hard Skills)
• External Relationship Management (Soft Skills)
• Reporting and Presentation Skills (Hard Skills)

Job Summary:

• Specialize in operational risk, analyzing loss risk involved with Experian’s Sure Profile warranty claims processes and system
• Responsible for developing, implementing and administering risk management program related to Sure Profile warranty claims risk
• Leverage Risk Management Information System (RMIS) to track and forecast claims and losses
• Configure RMIS to automatically evaluate eligible and ineligible warranty claims
• Configure RMIS to automatically respond with reason codes and status of claims
• Ensure proper monitoring, status, and tracking of open claims (those where all criteria to determine eligibility are not yet available)
• Design and enhance comprehensive reporting and dashboards for information management and risk oversight for senior leadership
• Direct management, claims teams, and other stakeholders
• Assess market and client unmet needs for Sure Profile warranty claims process and create a roadmap for process and software enhancements based on priority, opportunity
• Consult with Sure Profile product, dev, analytics, and risk management teams on warranty claim to value and process improvement opportunities

Skills on Resume: 

• Operational Risk Management (Hard Skills)
• Risk Management Program Development (Hard Skills)
• RMIS Utilization (Hard Skills)
• RMIS Configuration (Hard Skills)
• Claims Monitoring and Tracking (Hard Skills)
• Reporting and Dashboard Design (Hard Skills)
• Stakeholder Management (Soft Skills)
• Process Improvement and Roadmapping (Hard Skills)

Job Summary:

• Oversight and ownership of Sure Profile outcome reporting, which includes warranty claims submission file specification, submission logistics, client experience, and ongoing enhancement and optimization over time
• Evaluate and deploy the best use of risk management information system’s client-facing web portal as a companion to primary claims submission method
• Liaise with Finance, Legal, and Compliance on optimum claims payment method and tracking, enhancements to warranty claims criteria, gaming protection, and more
• Establish internal and external Service Level Agreement (SLA) policy for claims adjustment, client communications, status updates, forecasting, reporting, and more
• Develop warranty claim client-facing reason codes, parent and child, describing the reasons claims are approved, rejected, or pending
• Create and oversee the “Back-office” client dispute/appeals process
• Assist clients with warranty claims questions and service
• Monitor and respond to customer inquiries and requests on all warranty issues
• Ensure customer satisfaction and ensure compliance to all warranty specifications.
• Evaluate data sources contributing to warranty claims processing, identifying improvements in processing, efficiency, or accuracy in time with scaling of product

Skills on Resume: 

• Claims Management Expertise (Hard Skills)
• Risk Management Information Systems (RMIS) (Hard Skills)
• Cross-Functional Collaboration (Soft Skills)
• Service Level Agreement (SLA) Management (Hard Skills)
• Claims Reason Code Development (Hard Skills)
• Dispute Resolution and Appeals (Hard Skills)
• Customer Service Excellence (Soft Skills)
• Data Analysis and Process Improvement (Hard Skills)

Job Summary:

• Manage overall claims processing function, and ensure accurate and timely processing of claims within established legal and company compliance guidelines
• Meet and exceed all service level requirements
• Oversee and ensure achievement and maintenance of all claims processing standards within established guidelines
• Ensure compliance with all claims related to contractual, regulatory and legal requirements
• Analysis of claims payments and denials to identify and address trends and opportunities
• Identify and implement operational efficiencies and development of 'best practice' policies and procedures
• Overall management of complete and sound claim settlements, legal reviews and investigations in accordance with company policies and procedures.
• Analyze customer impact and respond to complex escalated customer service and claims processing issues to ensure that customer expectations are consistently met
• Deal with customer complaints and appeals accordingly
• Drive and manage quality and customer service standards
• Prepare and monitor claims expenses and administration budget
• Provide quality operational leadership

Skills on Resume: 

• Claims Processing Management (Hard Skills)
• Service Level Management (Hard Skills)
• Compliance Oversight (Hard Skills)
• Claims Analysis and Trends Identification (Hard Skills)
• Operational Efficiency and Policy Development (Hard Skills)
• Settlement Management (Hard Skills)
• Customer Service and Issue Resolution (Soft Skills)
• Quality and Standards Management (Soft Skills)

Job Summary:

• Contribute towards overall strategy and link to the setting of standards, targets, and overall objectives
• Ensure that all business process is followed
• Apply basic statistical analysis to track performance variations and resolve operational performance variations
• Produce and analyze weekly/monthly KPIs, dashboards and analytics to measure and improve performance
• Prepare and present management information and reports
• Ensure performance issues are identified and resolved accurately and timeously and implement action plans to proactively manage any foreseeable issues
• Analyze and evaluate business processes and recommend actions to streamline processes, improve operational efficiencies, and identify opportunities for reducing operational costs
• Overall management and effective operation of other service offerings, including pensions and ensure performance, quality, and customer targets within these services are met
• Keep up to date with current statutory regulations and monitoring changes in the legal requirements for other service offerings including pensions providers and developments in pension provision
• Work with the Support Services Manager in the preparation of audits and ensure compliance with all audit requirements
• Work with the Support Services Manager and Quality Assurance Team to ensure controls that prevent and eliminate fraud are in place at all times

Skills on Resume: 

• Strategic Contribution and Goal Setting (Hard Skills)
• Business Process Management (Hard Skills)
• Statistical Analysis (Hard Skills)
• KPI and Dashboard Management (Hard Skills)
• Reporting and Presentation (Hard Skills)
• Problem Solving and Action Planning (Hard Skills)
• Process Improvement (Hard Skills)
• Compliance and Audit Preparation (Hard Skills)

Job Summary:

• Work with the Support Services Manager and Investigator on complex or fraudulent cases and provide specialist knowledge where appropriate
• Represent the department in meetings with internal/external stakeholders
• Build strong business relationships with key clients and stakeholders
• Work with key stakeholders to improve the performance of the department
• Update job knowledge through the studying of trends and developments in claims processing
• Manage team measures and incentive criteria
• Proactively identify and manage personnel problems to ensure an engaged workforce
• Implementation of performance management standards to ensure high caliber team
• Bring expertise, experience, and skills and assist with continual training, coaching, mentoring, development, empowerment and performance of claims team.
• Drive an empowered and engaged high-performance culture focused on continuous improvement and service delivery

Skills on Resume: 

• Fraud Detection and Investigation (Hard Skills)
• Stakeholder Management (Hard Skills)
• Performance Improvement (Hard Skills)
• Knowledge Management (Hard Skills)
• Team Management and Leadership (Hard Skills)
• Training and Development (Hard Skills)
• Culture Building (Soft Skills)
• Problem Solving and Decision Making (Hard Skills)

Job Summary:

• Maintains oversight of the quality management functions. 
• Consult and work cross functionally to influence and promote change in order to deliver quality service to internal and external customers.
• Select and build strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques
• Manage the supervision of teams of analysts/auditors/consultantsDirect the development of quality assessment and audit programs, including purpose, scope and approach
• Develop, implement and manage quality improvement programs, initiatives, and standards
• Consults with internal/external customers on solutions that impact Quality
• Collaborate with other business areas to address quality issues 
• Lead or participate in group presentations on strategic quality management 
• Assist business partners in integrating quality into strategic and operational plansEstablish and assess standards of quality measures. 
• Measure performance against standards
• Develops and manages a business plan that addresses immediate and longer-term business demands
• Formulates and implements strategy for the unit to meet objectives
• Evaluate and prioritize recommendations for quality improvement initiatives to senior management and/or customers according to the value, risks, and importance to the organization that influences change/enhancements to business processes, policies, workflows, and systems in order to improve performance results and organization effectiveness. 

Skills on Resume: 

• Quality Management Oversight (Hard Skills)
• Cross-functional Collaboration (Soft Skills)
• Team Building and Development (Soft Skills)
• Program and Initiative Development (Hard Skills)
• Quality Improvement (Hard Skills)
• Consultative Approach (Soft Skills)
• Presentation and Communication (Soft Skills)
• Strategic Planning and Execution (Hard Skills)