AVP, Provider Claim Resolution

Summary of Position

Serve as the key operational liaison with Provider Network Management and Finance : responsible for the reconciliation, reprocessing / recoupment and provider communication for claim payment integrity challenges.

Oversee contract review; ensure that contract provisions are in alignment with corporate goals. Develop and implement dashboards to monitor performance.

Drive discussions directly with all Provider back office operations to resolve claim processing disputes, including over and under payments, in a timely manner with engagement from the Provider Network Management Relationship Managers to ensure the discussions follow the contractual agreement.

Responsibilities :

• Direct team to review claim A / R files, determine root causes and trends, build and implement corrective action plans, and drive reprocessing of claims where applicable.
• Ensure alignment between stakeholders of all processes related to overpayments / pay cycles : collaborate with Finance and other departments as needed to build, implement, maintain, and enhance a process to maximize efficiency and effectiveness of overpayment offset reconciliations.
• Drive discussions directly with Provider back office operations to explain findings and to obtain agreement from Provider back office operations on financial determinations from over / under payments.

Take steps to ensure that the work is fully integrated into a cohesive review of under and overpayments with the providers.

• Prioritize and schedule claim reprocessing through manual adjustments and recycle programs in alignment with Finance to ensure appropriate and timely cash flow release.
• Collaborate with Contract Configuration Team, Grievance & Appeals, Provider Services and Claims Quality to trend and evaluate Provider complaints and inquires, with the expectation of avoiding A / R file submissions.
• Research, review, and interpret existing contracts to discern any possible advantage for the company; may (re)negotiate contracts to provide favorable terms as well.
• Establish reserves based on A / R liability to minimize financial impact to the enterprise.

Qualifications :

• Bachelor's degree in Business Management or related; Master's degree preferred.
• Six Sigma / Project Management certification preferred.
• 10+ years of experience managing high volume HMO and / or PPO health insurance claims processing function across Commercial, Medicare and Medicaid segments. (Required)
• Additional years of experience / specialized training may be considered in lieu of educational requirements. (Required)
• Experience with an enterprise-wide healthcare software / system (that includes automated claims processing, billing, care management and network management workflow, etc.

preferably FACETS. (Required)

Strong knowledge of contract requirements, provisions, SLAs, metrics, terms, and other parameters that impact / measure overall performance and compliance;

and the ability to negotiate contract terms. (Required)

• Analytical skills with emphasis on generation and utilization of data to drive operational and financial performance. (Required)
• Ability to identify, quantify, and analyze problems; and to develop, recommend, and implement solutions effectively. (Required)
• Critical "end-to-end" thinker and business problem solver who moves quickly and decisively. (Required)
• Strong interpersonal, problem solving and project / time management skills. (Required)
• Excellent communication skills (verbal, written, interpersonal) with all internal / external audiences. (Required)
• Ability to effectively develop and deliver presentations to all levels within and outside of Emblem. (Required)
• Ability to work in a complex, rapidly evolving environment with multiple internal and external entities and boundaries. (Required)

Additional Information

Requisition ID : 1000001852

Hiring Range : $150,000-$280,000