Director of Claims and Customer Service

3 days ago

Janesville, United States Mercy Health System Full time
Overview

Directs the MercyCare operations including all processes associated with claims and customer service, appeals and grievances, coordination of benefits, auditing and subrogation for all product lines, including Medicare Advantage. This position is also a key member of the MercyCare management team, offering insight on all MercyCare operations, as well as contributing to strategic planning. This position is often asked to participate in functions involving the marketing of MercyCare products. Participates as a leader on various MercyCare and Mercy Health System committees.
Responsibilities

Essential Duties and Responsibilities
  • Responsible for setting goals and maintaining the MercyCare dashboard measures pertinent to customer service, and in support of both MercyCare and the Mercy Health System goals. Develops goals for each staff member and work group within the department. Responsible for initiating process improvement efforts within claims and customer service, to include other MercyCare departments as necessary to achieve goals. Works cooperatively with other directors, managers and vice presidents to ensure that MercyCare processes support the system's mission.Manages the analysis and reporting of annual CAHPS survey results, and provides MercyCare-wide action plans based on results.Designs, revises, develops and implements policies and procedures to ensure process flows are consistently followed, and the visions, mission and philosophies of Mercy Health System are maintained.Responsible for preparing budgets and managing within budgeted staffing levels. Hires and evaluates lead staff and partners by conducting employee reviews on time. Maintains an environment in which team work is encouraged, practiced and expected. Develops cross-functionality between and among the various job classes by ensuring the continual development of staff.Responsible for reviewing and confirming appropriate payments on all high dollar claim payments, and for obtaining any available discounts. Reports and discusses high dollar claims with management team. Manages the process of third party review of high dollar claims through a vendor relationship.Responsible for interpreting and implementing new government or NCQA regulations/guidelines affecting claims and customer service processes. Ensures compliance with state and federal regulations is maintained through regular audits.Uses available computer system reports to track claims and customer performance goals, and develops ad hoc reporting mechanisms when necessary.Maintains in-depth knowledge of PowerMHS transactional software.COMPETENCIES To perform the job successfully, an individual should demonstrate the following competencies:Quality - Follows policies and procedures; Adaptes to changes in the environment; Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance.Service - Responds promptly to requests for service and assistance; Meets commitments; Abides by MHS confidentiality and security agreement; Shows respect and sensitivity for cultural differences.Partnering - Supports organization's goal and values; Exhibits objectivity and openness to other's views; Gives and welcomes feedback; Contributes to building a positive team spirit; Generates suggestions for improving work.Cost - Conserves organization resources.Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.Technical Skills - Assesses own strengths and weaknesses; pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality.Oral Communication - Speaks clearly and presuasively in positive or negative situations; Listens and gets clarification; Participates in meetings.Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Fosters quality focus in others; Improves processes, products and services; Continually works to improve supervisory skills.Initiative - Volunteers readily; Seeks increased responsibilities; Asks for and offers help when needed.

Culture of Excellence Behavior Expectations

To perform the job successfully, an individual should demonstrate the following behavior expectations:

Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.

Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.

Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.

Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

Education and Experience

Bachelor's degree, or 10 years management experience in health insurance operations. Experience serving a diverse customer base. Must have in-depth knowledge of benefit plan design.

Certification and Licensure

N/A

Skills and Abilities
Management and team building; Ability to work with mathematical concepts; Must be organized and process oriented to manage day to day departmental functions; Must be able to plan, organize, prioritize and problem solve in pressure situations; Ability to define problems, collect data, establish facts, and draw valid conclusions; Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

COMPUTER SKILLS
Knowledge of insurance operations claims processing and customer service software, particularly PowerMHS; High level ability to work with Microsoft suite of office products.

Special Physical Demands

Sit for extended periods of time; Must be able to lift 25 pounds.

Level of Supervision

Work requires a high level of independent judgement. This position is expected to be self-directed, and has substantial latitude for independent action.

Supervises

Vice President

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