Operations/Claims Manager

Join to apply for the Operations/Claims Manager role at TakeCare Insurance Company, Inc. Job Specifications Graduate of Bachelor's Degree Minimum of 5 years experience in Health Insurance industry as Operations Manager; an exposure in BPO industry is an advantage. Must have strong background in initiating, developing, implementing and monitoring various administrative and management directed activities and programs that will strategically position TCAP with TKC organization. Strong managerial competencies in the areas of leadership and team development, managerial coaching and mentoring and situational assessment skills and with proven track record in building and developing high performing teams. A change agent and capable of guiding the organization in initiating various change management initiatives with the view of leading and guiding the organization towards the future. Strong managerial acumen in setting corporate directions and aligning strategic goals around business plans. Superior judgment, negotiation and decision‑making skills. Strong ethics and a high level of personal and professional integrity. Strong analytical skills and adept in interpreting strategic vision into an operational model. An effective communicator at all levels in the organization, with strong oral, written and persuasive skills. Responsibilities 1.1 Manage operational functions. 1.2 Increase the effectiveness and efficiency of Corporate Services through improvements to each function (HR, IT, Finance) as well as coordination and communication between functions. 1.3 Drive initiatives that contribute to long‑term operational excellence. 1.4 Provide consulting services on matters related to business structure and growth. 1.5 Develop strategic plans and programs to ensure that company’s goals and objectives for overall operational requirements are achieved. 1.6 Improve the operational systems, processes and policies in support of organization mission – specifically, support better management reporting, information flow and management, business process, and organizational planning. 1.7 Develop and monitor efficiency measurement tools. 1.8 Oversee overall TCAP financial management, planning, systems, and controls. 1.9 Manage the budget in coordination with the Executives. 1.10 Identify key activities and priorities. 1.11 Implement and communicate operational strategies and solutions in line with TakeCare’s goals and objectives. 1.12 Set and manage performance targets. 2.1 Contribute to short and long‑term organizational planning and strategy as a member of the management team. 2.2 Serve as primary liaison to legal counsel in addressing legal issues such as governing instruments, partnerships, and licensing. 2.3 Oversee organizational policies. 2.4 Ensure professional management standards are adhered to. 2.5 Ensure the operations business continuity and recovery requirements are met. 2.6 Ensure all policies and procedures relating to the company’s Directorate are appropriate to the business and operational needs of the organization. 2.7 Manage relationship development and interpersonal communication. 2.8 Ensure new policy development, implementation, and proper execution. 2.9 Perform various project management tasks as assigned by the Health Plan Administrator. 3.1 Ensure TCAP practices and operations comply with applicable PI licensure, accreditation, and legal requirements. 4.1 Develop, coordinate, and manage the annual budgeting and planning process for TCAP’s organization with the Executive Director. 4.2 Assist the Health Plan Administrator in creating the annual organizational budget and monitoring cash flow. 4.3 Develop long‑range forecasts and maintain long‑range financial plans. 5.1 Develop, implement, and maintain policies, guidelines, and procedures to ensure company‑wide consistency. 5.2 Design and develop appropriate organization structures for teams. 5.3 Establish performance improvement programs and provide coaching to underperforming staff. 5.4 Conduct training and development for staff to enhance technical competencies. Claims Processing Responsibilities 1.1 Assigned to process CMS‑1500 claims and UB‑04 claims for various facilities. 1.2 Examine claims with a payment security limit of less than $5,000. 1.3 Maintain a 95‑98% claims processing accuracy rate. 1.4 Meet the 30‑calendar‑day claims processing turnaround time. 1.5 Ensure strict compliance with HIPAA rules and regulations. 1.6 Service the Federal account and/or large commercial groups. 1.7 Respond to issues referred by the Customer Service Department within 2‑5 working days. 1.8 Respond to inquiries from internal departments and external customers in a timely and courteous manner. 1.9 Create and maintain a daily production report. 1.10 Update the daily batch log. 1.11 Routinely update milestones and goals within the performance goal. 1.12 Coordinate with the different departments on issues relating to systems, utilization management, enrollment, and membership. 2.1 Supervise the data entry, processing, and examination of all medical, dental and facility claims assigned to the team. 2.2 Monitor strict adherence to performance standards and established deadlines. 2.3 Conduct performance appraisal and coaching to ensure prescribed output and indicators are met. 2.4 Conduct behavioral counseling in accordance with company policies, rules and regulations. 2.5 Compile and submit daily, weekly and monthly departmental reports to management. 2.6 Support department performance standards and quality improvement processes. 2.7 Ensure compliance with policies, procedures and practices. 2.8 Facilitate regular and periodic meetings to evaluate team performance. 2.9 Develop a team culture that values innovative thinking to improve the efficiency of the claims handling process. 2.10 Recommend and implement appropriate training programs to further enhance staff technical competencies. 2.11 Assist in writing policies and procedures for the department. 2.12 Participate in the hiring and/or termination of staff in collaboration with Human Resources. 2.13 Train new employees on policies and procedures. 2.14 Coordinate with different departments on issues relating to systems, utilization management, enrollment and membership. 2.15 Perform other duties as assigned. #J-18808-Ljbffr