Health Insurance Operations Manager jobs in Stamford, CT

ABOUT THE ROLE: 

The Manager of Claims Operations/Payment Integrity will play a key role in achieving the highest-level of claims excellence through creation and implementation of consistent business processes aligning with strategic goals of the XO Health Operations Department. The Manager of Claims Operations/Payment Integrity will work closely with the SVP of Operations and Payment Integrity and other departments to develop, communicate, implement, execute, and measure claim business processes. 

RESPONSIBILITIES: 

• Direct day-to-day operations of claims processing department to ensure that claims are processed within statutory and company guidelines. 
• Ensure procedural and financial claims metrics and service level agreements are met. 
• Involved in detecting and correcting claim-based factors such as errors, coding guidelines, fraud, waste, abuse. 
• Collaborate with leadership from cross functional departments to ensure efficiency and proper prioritization of the claims adjudication process. 
• Provide regular feedback regarding claim processing performance in critical areas such as compliance policy, process and procedure adherence, and customer satisfaction. 
• Implement and lead operational improvement efforts that produce successful results in the aforementioned areas. 
• Coordinate with the Claims Vendor Manager and assist with the development, aggregation, and communication of vendor KPI's and performance. 
• Assist in the development of claims best practices, including but not limited to, claim processing guidelines, policies and procedures, job aids, and claims bulletins. 
• Act as a liaison with other departments to obtain and analyze information to further improve claims handling practices and customer relationships. 
• Monitors performance, reviews open and closed claims to ensure that claims have been properly handled and moved towards resolution in a timely manner. 
• Supports training of claims examiners, claims managers, and senior claims leadership. 
• Acts as an SME resource regarding coverage issues, reserves, exposure, settlement value, and strategy. 
• Submits weekly management reports and prepares special reports when requested. 
• Responds to inquiries from various other departments with reaction to claim handling, processing, and coverage issues. 
• Assists in the conducting of audits of vendors, both primary and independent. 
• Available in an emergency 24/7 and extended hours as needed. 
• Work with quality assurance personnel and assist as needed. 
• Assists senior management with other projects and initiatives as requested. 
• Travel if needed to support train-the-trainer sessions for operational claim staff. 
• Travel for participation in business management meetings, and support of other business initiatives. 

EXPERIENCE REQUIRED: 

The qualified candidate will have: 

• 5 years of proven medical claims operations leadership experience. Bachelor’s degree in healthcare administration or equivalent relevant work required. 
• Strong knowledge of medical terminology, health insurance plans, medical billing concepts. 
• In-depth understanding of Facility, Facility Stoploss, DME, Behavioral Health, Coordination of Benefits claims processing. 
• Excellent written and oral communication skills. 
• Excellent customer service and follow-up skills. 
• Strong organizational leadership skills and detailed oriented. 
• The ability to manage multiple projects at one time. 
• Analytical, strategic minded and goal oriented. 
• A leader with the ability to work independently. 
• Strong attention to detail.