Job Group Summary
Customer Service is the important first-line of contact with customers, setting the tone for how members, doctors, and plan sponsor groups view our company.
It provides members with the right information at the right time to help them make better decisions about their health and health care.
Family Summary / Mission
To increase member satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes.
Position Summary / Mission
Responsible for the overall supervision of the Claim processing employees. Accountable for member / provider / broker satisfaction, retention, and growth by efficiently delivering competitive services to members / providers.
Fundamental Components & Physical Requirements
Develops, trains evaluates and coaches staff / self to provide cost-effective claim review / processing and claim service while ensuring quality standards are met.
Acts as liaison between staff and other areas, including management, plan sponsors, provider teams, etc., communicating workflow results, ideas, and solutions.
Assesses individual and team performance on a regular basis and provides candid and timely developmental feedback.
Develops training plans and ensures training needs are met.
Establishes clear vision aligned with company values motivates others to balance customer needs and business success
Attracts, selects, and retains high caliber, diverse talent able to successfully achieve or exceed business goals.
Builds a cohesive team that works well together Proactively analyzes claim / constituent data, identifies trends and issues.
Recognizes and acts on the needs to improve the development and delivery of products and services.
Clearly identifies what must be accomplished for successful completion of business objectives
Leverages the unit's resources to resolve plan, claim and call inquiries or problems by identifying the issue, obtaining applicable information, perform root cause analysis, and generate and act upon the solutions
Manages and monitors daily workflow and reporting to ensure business objectives are maintained and accurately reported ensures resources are aligned appropriately across function and / or service center
Effectively applies and enforces HR policies and practices, Attendance, Code of Conduct, Disciplinary Guidelines Ensures regulatory compliance with policies and procedures
Supports Complaints process as required May audit and adjudicate high dollar claims that exceed the processor draft authority limits
Utilizes available incentive programs to reward, recognize, and celebrate team and individual's success
Allocates resources to meet volume and performance standards including Key Performance Metrics (KPM's) and Performance Guarantees
Initiates and maintains partnerships with others throughout the organization and various vendors
Ensures compliance with the requirements of regional compliance authority / industry regulator
Adheres to international privacy policies, practices, and procedures
Background Experience Desired
Experience with claim / call center environment.
3+ years claims processing experience.
Education and Certification Requirements
University / college degree preferable or equivalent work experience.
Higher education or local market equivalent.
Strong project management skills.
Solid written and oral communication skills.
Solid leadership skills including staff development.
Outstanding customer service skills are required.
Prioritizes tasks effectively.