Operations/Claims Manager

Job Specifications:

1.     Graduate of Bachelor's Degree

2.     Minimum of 5 years experience in Health Insurance industry as Operations Manager; an exposure in BPO industry is an advantage.

3.     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.

4.     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.

5.     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.

6.     Strong managerial acumen in setting corporate directions and aligning strategic goals around business plans.

7.     Superior judgment, negotiation and decision-making skills.

8.     Strong ethics and a high level of personal and professional integrity.

9.     Strong analytical skills and adept in interpreting strategic vision into an operational model.

10.  An effective communicator at all levels in the organization, with strong oral, written and persuasive skills.

Duties and Responsibilities:

1.     Organizational Effectiveness

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.  Providing consulting services on matters related to business structure and growth

1.5.  Develops 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 organizations mission -- specifically, support better management reporting, information flow and management, business process and organizational planning.

1.7.  Develops and monitors efficiency measurement tools.

1.8.  Oversee overall TCAP financial management, planning, systems and controls.

1.9.  Management of budget in coordination with the Executives

1.10. Identifies key activities and priorities.

1.11. Implements and communicates operational strategies and solutions in line with TakeCare's goals and objectives.

1.12. Sets and manages performance targets.

2.     Organizational Leadership

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 e.g. governing instruments, partnerships, licensing etc.

2.3.  Oversee organizational policies.

2.4.  Ensures professional management standards are adhered to.

2.5.  Ensures the operations business continuity and recovery requirements are met.

2.6.  Ensures all policies and procedures relating to the company's Directorate are appropriate to the business and operational needs of the organization.

2.7.  Relationship management and interpersonal development.

2.8.  Ensures new policy development, implementation and proper execution.

2.9.  Various project management tasks as assigned by the Health Plan Administrator.

3.     Regulatory Compliance

3.1.  Responsible for working with other internal and external PI and Guam entities to ensure TCAP practices and operations are compliant with applicable PI licensure, accreditation and legal requirements.

4.     Financial Management

4.1.  Develop, Coordinate and manage of annual budgeting and planning process for TCAP organization's annual budget with ED.

4.2.  Assist Health Plan Administrator in creating annual organizational budget and monitoring cash flow.

4.3.  Develop long-range forecasts and maintain long-range financial plans.

5.     General Management

5.1.  Planning

Develops strategic plans and programs for TCAP and ensures that goals and objectives of the team are properly defined and clearly established and communicated to direct report organization.

Develops policies, guidelines, and implementing procedures and ensures consistent company-wide implementation.

Develops budgetary plans, programs, and guidelines to ensure the team's strict adherence with financial guidelines and requirements.

Ensures that operating expenses are well within the prescribed limits of budget plans and fiscal guidelines.

5.2.  Organizing

Designs and develops the appropriate organization structure for the team.

Delineates, defines, and streamlines its various functional activities, thereby ensure its effectiveness in maximizing the utilization of both asset and people resources.

5.3.  Leading

Performs selection and staffing functions such as:

5.3.2. In collaboration with Human Resources Department, conducts in-depth assessment interviews to determine the technical and behavioral competencies of the candidate to ensure that the best from among the qualified candidates are being hired in the company.

5.3.3. Adheres to and implements the philosophy of "hiring the best fit" and ensures that prospective employees' personal values are aligned with the company's corporate values.

5.3.4. Conducts regular and periodic meetings with the operations team, to ensure the following:

5.3.5. Implementation of all plans, programs, and projects are strictly adhering to prescribed deadlines and schedules.

5.3.6. All communications and relevant information pertaining to the team are cascaded to the proper channels within the team in particular, and the organization in general. 

5.3.7. Coordinates with functional manager "Performance Improvement Program", through the following:

5.3.8. Assist functional manager in coaching the staff who failed to perform and deliver the prescribed and committed level of performance output and standards.

5.3.9. Performance mentoring for high potential staff, capable of assuming bigger responsibilities in the future.

Recommends training and development functions, as follows:

Recommends and implements for appropriate training programs that will further enhance and hone the technical competencies of the staff.

5.4.  Controlling

5.4.1. Assist functional managers in reviewing and evaluating the performance of the team, on regular and periodic basis, and ensures that the overall performance of the team is on-track, and well within the pre-established goals and objectives.

5.4.2. Consolidates performance status reports of the team as basis for monitoring the weekly progress of the various activities within the team.

5.4.3. Involves functional manager, local HR and/or HR Director regarding benefits, employee relations, performance reviews, and trainings.

Duties and Responsibilities as Claims Manager:

1. Claims Processing

1.1.  Assigned to process On-Island, Outer-Island and/or Off-island professional/specialist (CMS-1500); outpatient facility and hospital inpatient, outpatient, ER (UB-04) claims.

1.2.  Examines claims with a payment security limit of less than $5,000.00.

1.3.  Responsible for maintaining a 95-98 claims processing accuracy rate.

1.4.  Meets the 30 calendar day claims processing turnaround time.

1.5.  Strict compliance of all HIPAA rules and regulations.

1.6.  Assigned to service the Federal account and/or large Commercial groups.

1.7.  Responds and solves issues referred by the Customer Service Department within 2-5 working days.

1.8.  Responds to inquiries from internal departments and external customers in a timely and courteous manner.

1.9.  Creates and maintains a daily production report.

Updates the daily batch log.

Routinely updates milestones and goals within the performance goal.

Coordinates with the different departments on issues relating to systems, utilization management, enrollment and membership.

2. Leading

2.1.  Supervises the data entry, processing and examining of all medical, dental and facility claims assigned to the team.

2.2.  Monitors strict adherence to performance standards and established deadlines.

2.3.  Conducts performance appraisal and coaching to ensure prescribed output and indicators are met.

2.4.  Conducts behavioral counseling in accordance with company policies, rules and regulations, due process, and government regulations.

2.5.  Responsible for compiling and submitting daily, weekly and monthly departmental reports to management.

2.6.  Supports department performance standards and quality improvement processes.

2.7.  Ensures compliance with policies, procedures and practices.

2.8.  Facilitates 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. Recommends and implements appropriate training programs that will further enhance the technical competencies of the staff.

2.11.  Assists in the process of writing policies and procedures for the department.

2.12. Participates in the hiring and/or termination of staff in collaboration with Human Resources Department.

2.13. Trains new employees on policies and procedures.

2.14. Coordinates with different departments on issues relating to systems, utilization management, enrollment and membership.

1. Performs other duties as assigned.