SUMMARY: Supervises, identifies and implements improvements and coordinates the work processes in the Claims and Customer Service Departments as well as with external stakeholders.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Hire, supervise and evaluate customer service staff and operations direct report(s) (i.e. Eligibility/Operations Specialist) staff based on established performance dimensions, standards and goals.
- Hire, supervise and evaluate claims manager.
- Develop and implement recommendations to increase the efficiency and effectiveness of the claims and customer service department. This would typically include working with other internal departments, particularly MIS, to implement changes.
- Ensure efficient and effective claims entry, repricing, eligibility processing, and customer service. This includes development and maintenance of a performance monitoring system and audit procedures.
- As the HIPAA Privacy Officer, ensure organizational compliance with HIPAA privacy requirements. Specific responsibilities are stipulated in the “Privacy and Security Oversight Policy and Procedures.”
- For outside network repricing clients (i.e. FABOH), coordinate the implementation of new provider and employer groups into the repricing system.
- Continuously develop and maintain strong working relationships with TPAs, employer groups, outside vendors, and providers.
- Participate in problem solving with these groups that address both day-to-day problems and, more importantly, the root cause of the problems.
- Support statistical reports (TPA Scorecard and other specialized reports) that monitor performance and then taking appropriate action to enhance performance
- Engage in general relationship building to enhance goodwill and cooperation among these important stakeholders.
- Present to TPAs, providers, and employer groups about The Alliance Claims and Customer Service functions as well as the consumer-oriented services of The Alliance (provider directory, cost estimates). This includes offering and meeting occasional training needs for TPAs and providers.
- Oversee the claims operations and customer service aspects of serving other coalitions (i.e. FABOH) claim repricing services.
- Maintain communication regarding claims and repricing system updates and changes with providers, benefit plan administrators and internal staff.
- Develop, maintain and implement a data entry operator and customer service representative training manuals, and TPA toolkit to include claims operations policies and procedures.
- Take the lead in the department to pilot new products/offerings (i.e. cost estimator, claims portal, TPA Scorecard, and determine how best to structure service delivery in the department or organization after the pilot.
SUPERVISORY RESPONSIBILITIES: Claims and Customer Service Department personnel.
QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience: Two-year associate degree and at least five years of related experience and/or training; or equivalent combination of experience and education. Previous supervisory experience required. Alphabetic and numeric data entry skills required.
Language Skills: Strong written and verbal communications skills. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions.
Mathematical Skills: Ability to apply concepts of basic mathematics.
Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exits.
Other Skills and Abilities: A solid background in using personal computers is essential and must include knowledge of Microsoft Office.
Certificates, Licenses, Registrations: Wisconsin driver’s license.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee is frequently required to use hands to finger, handle or feel objects, tools or controls. Specific vision abilities required by this job include close vision and ability to adjust focus.
Occasionally lifting and/or move up to 20 pounds.
WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
As a not-for-profit cooperative, The Alliance is employer-owned and remains a trusted, objective partner for employers and their brokers who seek improved access to high-value healthcare.
We’re Madison-based, but we work with 340+ employers across the Midwest and contract with over 38,000 doctors and other healthcare providers in the region. Our goal is to help employers better manage their healthcare costs while remaining transparent and emphasizing value – creating healthier, more engaged workforces.
The Alliance is celebrating over 30 years as a mission-driven and member-focused collective with experienced leadership and strong organizational departments backed by top talent. By joining The Alliance, you’ll become part of a passionate, collaborative, and supportive organization: one that fosters meaningful connections and relationships with high levels of employee engagement and satisfaction.
Our health plan is self-funded, which means we share the same interests and use the same tools that we offer our clients. We lead by example because when we take care of our employees, they take care of our clients (and their employees).
Our DEI Commitment
Diversity, Equity, and Inclusion (DEI) are critical for The Alliance to realize Our Vision and attract, retain, and excite exceptional people. The Alliance is committed to embedding DEI into our culture such that diverse experience and perspectives are valued and welcomed, driving innovative solutions for our employer members, employees, and their families.