SUMMARY Under the direction and in support of operational leadership, this role will be responsible for several key components of WIN’s claims and health plan coordination functions. Involves “hands-on” daily interaction with all levels of staff and other relevant departments, particularly IT and the PMO. Recommends and implements initiatives to improve department efficiency, productivity, workflows, and costs. Responsible for delivery of quality claim process management to members, providers and pharmacies that exceeds customer expectations, company standards and contract obligations. ESSENTIAL FUNCTIONS Critical features of this position are listed below and may be revised, updated or reassigned at management’s discretion in accordance with business needs or other factors. • Plans, organizes and manages key claim functions. • Works “on the floor” and coaches team members in the supervision of all tactical and strategic activities. • Drives performance by ensuring all employees are trained, and work is completed in accurate timely manner and meets company and contractual standards. • Monitors and tracks staff and department 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 work queues, prioritizes incoming authorizations and effectively delegates tasks to team staff to ensure company standards and contract obligations are met. • Handles complex customer issues escalated by team members. Assists staff in troubleshooting techniques 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 WIN’s policies, standards and procedures. Resolves any issues or directs claim to team lead/area manager for resolution prior to payment. • Conducts regular customer service audits to ensure accuracy and timeliness consistent with company and or client standards. • 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 with Human Resources. • Prepares and presents a variety of management reports, including explanation of variances, significant trends, and recommendations for change or resolution. Keeps department management adequately informed of 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. Page 2 • Follows and ensures team follows HIPAA and URAC protocols when discussing or accessing protected health information. SUPERVISORY RESPONSIBILITIES Responsible for direct supervision of various levels of staff within the operations area. 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. MINIMUM QUALIFICATIONS • Bachelor’s degree in a business-related subject or equivalent experience. • At least seven years operational supervisory experience managing and training a claims service unit with a healthcare payer, delegated vendor, or TPA, supervising a team of agents. • Expertise in claims adjudication, including interface with payers 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 payers, EFT, transmission of forms, and web portal interface for providers and members. • Working knowledge of current commercial health insurance product options, including HMO, PPO, EPO, high deductible plans, copay/coinsurance variations, and HRA’s/HSA’s. • Strong performance management and productivity optimization skills, including reporting, analysis and recommendations. • Strong technology background interfacing with IT personnel. • Strong working knowledge of MS Office products, primarily Excel. • Knowledge of ICD-10, NDC/GPI, and CPT/HCPCS coding. • Thorough HIPAA knowledge. KNOWLEDGE, SKILLS AND ABILITIES • Claims management experienced within healthcare payer environment. • Microsoft Office fluency