Rating/Claims System Senior Advisor

2 weeks ago

Columbus, United States Elevance Health Full time

Rating/Claims System Senior Advisor

Location: This position will work a hybrid model (remote and office). The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations in Columbus, OH; Mason, OH; Indianapolis, IN; Chicago, IL; Manchester, NH; Boston, MA.

The Rating/Claims System Senior Advisor leads the activities for India based Commercial Claims Operations, Claims System Configuration, and Provider Data Management departments to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achievement of cost objectives and service level goals; provider data management and related downstream processes; collaboration with all other client departments to ensure client goals are achieved and compliance with guidelines are met.

How you will make an impact:

  • Establish standards of performance, including training, policies and procedures, claims auditing and other performance measurement techniques.

  • Oversee all activities related to claims processing.

  • Primary oversight and responsibility for delegated claims functions performed by third party vendor, including claims processing and fulfillment.

  • Oversee the coordination of procedures for administering the various benefit plans and provider contracts with all interfacing systems.

  • Responsible for implementing and auditing benefit changes as related to claims processing.

  • Responsible for monitoring Medicare changes as they relate to claims payment and methodologies, benefits and coding and billing.

  • Develop and implement cost control measures.

  • Responsible for directing the processing and payment of claims.

  • Provides guidance on the most complex claims.

  • Develops short/long-term objectives and continually monitors procedures to ensure these are met by staff.

  • Stays abreast of state/federal regulations.

  • Manages commercial claims processing team located in CGS's India site.

  • Works with business owners to identify and analyze requirements and processes with Information Technology and the vendor to ensure quality and timeliness of systems/project deliverables.

  • Position requires significant and regular external contact with customers or regulatory agencies.

  • Has significant budget accountability and manages special projects.

  • Translates the most highly complex and varied business needs into application software functionality.

  • These needs typically involve a significant expenditure or cost savings and impact a wide range of functions.

  • Configures new designs/updates in the system.

  • Monitors system and business functionality and performance.

  • Documents and tracks product defects.

  • Coordinates problem resolution with development and/or product vendors.

  • May implement rates, rating formulas, product and benefit configuration/information and as directed by the appropriate business unit.

  • Analyzes, develops and validates data.

  • Researches, documents and completes very diverse and complex projects and work processes to ensure business continuity and consistency.

  • Formulates and defines system scope and objectives based on user-defined requirements.

  • Supports and maintains the systems post-implementation.

  • Provides end user support, consultation, liaison communications, helpdesk triage, training, reporting, auditing, application security, and ad hoc inquiries and requests.

  • Provides expertise to lower level analysts.

Minimum Requirements:

Requires an BA/BS degree in Information Technology, Computer Science or related field of study and a minimum of 8 years systems analyst or business analyst experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

  • 8-10 years of leadership and Managed Care experience, preferably in Medicare Advantage strongly preferred.

  • Experience working closely with offshore IT support team strongly preferred.

  • Experience with Medicare and corresponding regulatory requirements preferred.

  • Comprehensive knowledge of the health insurance industry, including, but not limited to: claim adjudication procedures; insurance law; benefit design; plan document provisions and compliance regulation strongly preferred.

  • Excellent analytical ability, written, oral and interpersonal communication skills, negotiation skills, PC skills, advanced strategic planning, organizational, managerial and leadership skills strongly preferred.

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