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Job Description

• Participating actively as a key member of the PAS’ Management Team, including demonstrating leadership through strong communications skills, use of business metrics to determine strategy and resource needs, and showing a high level of focus on continual quality improvement.

• Coordination of all activities of the Claims Department Management Team. This includes Supervisors and/or Team Leaders assigned to PAS’ Customers.

• Responsibility for Claims Department strategy, planning, staffing projection, budgeting and quality assurance and improvement.

• Responsibility for final hiring decisions on employees within the Claims Department. This is to ensure that high standards are maintained, and compensation arrangements are discussed and approved by Human Resources and the Chief Operating Officer of PAS.

• Creating a culture within the Claims Department of exceptional service to members and their providers, as well as transparency in reporting results, trends and issues to Senior Management and clients.

• Management of relationships with Preferred Provider Organizations and Reference-Based Pricing vendors which are essential to managing the cost of claims for clients.

• Management of relationships with essential vendors involved with the Claims Adjudication process, including clearinghouses, claims cost control vendors and the claims fulfillment vendor (printing and mailing of checks and EOP/EOB, as well as electronic payments).

• Identification and management of Subject Matter Experts (SMEs), with back-ups in various aspects of Claims, including procedures and use of technology.

• Oversight of Claims Training programs, including training for new employees and ongoing reinforcement training.

• Oversight of Claims documentation, including Policies and Procedures and reference materials.

• Participates in RFP/Proposal processes, including participation when requested in prospective client presentations.

Essential Duties Specific to Claims Department:

• Participation in product development, including the technical review of new products and prospective new clients. This assistance will be focused on evaluation and interpretation of benefits, advancements in health care requiring updates to programs and plans, and advancements in administration, including use of AI.

• Ensuring that daily reporting provides an accurate portrayal of claims on hand, including those received by the clearinghouse, sent to re-pricing entities, unable to be systematically “matched”, auto-adjudicated, in Examiner queues waiting to be adjudicated, and in either audit or needing approval status.

• Developing and implementing strategies for greater automation in the claims process, including electronic receipt of claims and auto-adjudication.

• Establishing production requirements for Examiners, and along with the Supervisor monitoring performance against the requirements.

• Establishing and monitoring strong operational controls relating to claims cost control, including review processes for potential pre-existing conditions, determining medical necessity, enforcing reasonable charge provisions and pursuing recovery of third-party liability.

• Monitoring and continually developing Policies and Procedures intended to enforce consistency in process and improve quality.

• Working with the Manager of Quality to implement appropriate standards for accuracy and audit procedures intended to validate those standards are met. This includes setting release authority levels and random audit percentages for Examiners reflecting experience and historical quality results. It will also include development of coaching and training programs linked to emerging quality issues.

• Using audit results to develop ongoing training programs and new procedures intended to increase procedural, payment and financial accuracy percentages.

• Coordinating escalations from other Departments with the Claims Supervisor to ensure that timely and complete actions and responses are provided.

• Reviewing and approving higher dollar claims prior to payment.

• Oversight for the ongoing management of claims processing technology, including plan building and identification of new and updated benefit categories based on new medical coding and medical services.

• Act as a liaison with clients for escalation of service issues or program questions, establishing a strong working relationship and client trust.

• Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS.

Participates in Product Development and Sales processes, including participation when requested in prospective client presentations, regulatory reviews and contracting of vendors.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to [email protected] learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.

Skills and Requirements

• A minimum of at least 5-7 years in a Management role for Claims Operations, servicing health insurance policies or benefits.

• Strong organizational, interpersonal and motivational skills.

• Excellent written and verbal communication skills.

• A college degree is preferred.