Director - Claims BPO

Assist the OPS BPO Directors in the day-to-day oversight of the Company’s Claims (Blue Card, FEP, Basic, OCL) and Membership processing through the managed business relationship with the outsource vendor. Works with vendor management to ensure timely processing of the Company’s claims and membership through continuous process improvement to ensure satisfactory performance levels, that standards are met, and to ensure all government programs are following mandated requirements and performing to BCBSRI standards. Develops and maintains reports and conducts detailed analysis and audits of operational data and policies that impact the Company’s ability to meet mandated requirements and standards. Responsible for ensuring that the Supplier is fulfilling all contractual obligations as they relate to claims and membership operations.REPRESENTATIVE JOB DUTIES :Participates with departmental directors in the formulation of the Company’s near term and long range claims and membership processing goals and objectives, and the plans and programs directed toward their achievement relative to the contract. Interact and partner with all areas of the Company to define and implement opportunities for improved claims and membership processing, which may include establishing cross functional programs and processes which incorporate improved technology and enhanced training programs to better respond to claims and membership volume fluctuations.Assist the directors in developing strategic project plans and implementation time frames relating to Claims and Membership functions. Evaluate corporate strategies and identify impacts on the organization. Make recommendations to directors for efficient implementation of plans. Acts as a liaison across the corporation in relation to the communication and execution of Claims and Membership specific issues and special projects.Identify, collect, and continuously maintain critical data as it relates to Claims and Membership. Assist directors in monitoring the effectiveness of vendor performance or joint activities through report analysis.Responsible for the administration and monitoring of contractual commitments, including establishing and maintaining all necessary Agreement related documentation, communication logs and reference material required by the Ops BPO area to effectively manage the Agreement. Responsible for ensuring that the Supplier (Perot Systems) is fulfilling all contractual obligations as they relate to Claims and Membership Operations.KNOWLEDGE, SKILLS & ABILITIES REQUIRED:Knowledge of:Health insurance and/or managed care industry with a focus on claims, enrollment, billing, customer service, and familiarity with computerized information tracking and processing systemsOverall corporate structureTechnical Skills:Strong PC skills including word processing and basic database skillsStrong programming and report production, graphics, and spreadsheet applications is beneficialKnowledge of Crystal Reports, MS Excel, Power PointAbility to:Handle multiple priorities.Exercise sound judgment.Take initiative in finding solutions to difficult and/or sensitive problems.Perform other duties as assigned.QUALIFICATIONS:Minimum Education and Experience:Bachelor’s degree or equivalent work experience related to health insurance claims administration.Five to eight years of management or equivalent work experience in health insurance claims and/or membership administration.Preferred Education, Additional Qualifications and Experience:PC skills, knowledge of claims and enrollment guidelines, State and Federal laws as applicable to the health insurance industry, including HIPAA.Prior insurance industry experience in customer billing, claims, systems, or professional relations is helpful.Knowledge and ability to report and interpret market, utilizations, customer satisfaction, and quality data.Working knowledge of PC-based reporting databases, programming and report production, graphics, word processing, and spreadsheet applications is beneficial.At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, gender identity or expression.Blue Cross experience,Health care knowledge,Investigation/Claims,Leadership/supervisory experience,Problem solving,See job description,Written and verbal communication skills