JOB SUMMARY:

Incumbent will provide leadership and direction for claims administrative and support functions including application development and oversight, liaison between quality assurance and training, defect reduction initiatives and process improvements.  Responsible for acquisition activity as it relates to claims due diligence and implementation. Responsible for planning, implementing and controlling the strategies and programs of the Claims Department that will ensure efficient operations, customer satisfaction and quality service with emphasis on defect reduction.  Ensures business processes and results demonstrate adherence and compliance with federal/state/regulatory standards and procedures while meeting company goals and objectives. 

PRIMARY RESPONSIBILITIES:   

1.      Interfaces with and builds internal and external relationships to ensure superior service.  Works with business partners such as the Health Plans, Providers, and internal  departments.

2.      Manages, controls, directs and takes corrective action with specific strategies to ensure overall performance meets Federal, State and Regulatory requirements.

3.      Evaluates the Claims Operations to develop and implement specific improvement programs to correct deficiencies in order to meet specific service standards.

4.      Has responsibility for meeting all cost, quality and performance objectives that strengthen the company’s ability to manage SG&A expenses and supports the medical expense objectives to ensure the corporation meets its financial goals.

5.      Supports the strategic planning process for the Claims Department that supports the overall mission and financial goals of the organization.

6.      Manages and monitors departmental budget.  Monitors and controls expenses by ensuring adequate departmental controls and prudent oversight of discretionary expenses.

7.      Develops and implements new, more efficient or cost effective methods or those required by changes in the business environment as it relates to claims processing.

8.         Key participant in activities related to corporate Mergers and Acquisitions to ensure successful transition of core business functions.

9.         Responsible for compliance with all Sarbanes-Oxley controls/compliance.  Responsible for process controls across multiple platforms.

10.     Other duties as assigned or requested.

Education and Experience:

SCOPE INFORMATION

PHYSICAL REQUIREMENTS

• Must be able to operate a computer

• Must be able to operate a telephone
• Must be able to travel on common carriers and adhere to   travel policies
• Must be able to conduct, actively participate or facilitate meetings