Coverage Review Operations

5 months ago

Scottsdale, United States The Cigna Group Full time

Coverage Review Operations provides a variety of clinical services that help health plans and pharmacy benefit managers protect patient health and safety and improve affordability while reducing unnecessary costs.  The Director is responsible for the daily oversight and management of an expansive team (500+ FTEs) consisting of internal and onshore and offshore supplier representatives.  This role is responsible for day-to-day operations in alignment with volume and channel forecasts balancing client Performance Guarantees and Service Level Agreements as well as helping to formulate and execute strategic operations roadmaps.  This includes partnering with outsourced leadership to ensure that our Global Service Partners (GSP) are motivated and receive proper direction to achieve top performance against quality, operational efficiency, and adherence to policy, procedure, and defined process, delivering optimal provider and member experiences. 

Primary Responsibilities

  • Provides direction and is accountable for the execution of prior authorization reviews and direct member reimbursement claims in accordance with client benefit intent policies and regulatory requirements.
  • Effectively communicates to team members with varying levels of Coverage Review and Direct Member Reimbursement subject matter expertise.
  • Gathers insights and makes data-driven decisions while understanding future planning of the areas supported to ensure a true strategic partnership delivering to our most critical stakeholders.  
  • Owns operational results and outcomes.
  • GSP management with accountability of various functions such as operational performance (quality, productivity), achievement of service level agreements, alignment of staffing models and training plans, and review/ reconciliation of monthly invoices.
  • Accountable to continuously assessing Business Process Outsourcing (BPO)/GSP footprints both onshore and offshore, current/ future strategic relationships, and business continuity planning.   
  • Sets goals aligned to the Enterprise strategy and motivates a team of people with diverse skills, responsibilities, and geographic locations towards these goals.
  • Ensures organizational alignment through cooperative development of individual and departmental objectives and provides individual, organizational, and global supplier partners feedback on performance on a continuous basis.
  • Interacts with and influences senior leadership.  Makes decisions that have a short to medium-term impact across the function as it relates to both our internal stakeholders and global service partners.
  • Attracts, retains, and develops top talent.
  • Provides strategic thought leadership and drives continuous improvement to advance provider and member experiences/ partnerships, leading to reduced expense and increased customer satisfaction.
  • Identifies opportunities for process improvement and works with partners to implement.
  • Provides insights into the creation of a multi-year people, process, and technology roadmap.

Key Qualifications

  • Bachelor’s Degree; Advanced degree strongly preferred.
  • 8 plus years of relevant experience; to include experience developing and executing core operations functions and strategies.
  • Experience with leading a large team overseeing broad scale operations with strong cross-functional partnerships (Global supplier partners/ BPOs, HR, workforce management, Account teams, technology, shared services such as quality, training, project management, etc.).
  • Demonstrated effectiveness working in a highly matrixed organization.
  • Ability to manage change, timelines, and balance multiple deadlines in a very fast-paced environment.
  • Advanced problem-solving skills and ability to work collaboratively through complex matters with innovative solutions.
  • A passion for employee engagement and leadership development.
  • Strong business and financial acumen.
  • Strong written and verbal communication skills, to interact effectively with all levels of management including executives, employees, customers, technology staff, and Global Service Partners.
  • Considerable knowledge of and experience in managing day to day operations and staffing needs with the ability to prioritize multiple projects.
  • General understanding of healthcare and health insurance businesses and regulatory/CMS guidelines.
  • Ability to think and act strategically and proactively. Proven track record of success in senior leadership positions.
  • Serves as an advocate and change agent, influences courageously at all levels of the organization.
  • Anticipates internal stakeholder and external client needs, investigates the underlying cause(s), and identifies short- and long-term solutions.

CRITICAL LEADERSHIP COMPETENCIES:

  • Delivers Results – Pushes team and cross functional partners to deliver needed results in tough circumstances and expedited timelines.
  • Builds Effective Teams – Builds strong identity teams that apply their diverse skills and perspectives to achieve common goals.
  • Manages Complexity – Makes sense of complex and sometimes contradictory information to effectively solve problems.
  • Manages Ambiguity – Operates effectively and drives work forward even when things are not certain or there is no clear way forward.
  • Collaborates – Quickly builds partnerships and works collaboratively with others to ensure progress.


  • Insurance Coverage Specialist

    4 weeks ago

    Scottsdale, Arizona, United States NAPAA Full time

    Job DescriptionThe Personal Lines Customer Service Representative at Misty Everette Allstate Agency is responsible for maintaining solid customer relationships by handling personal lines insurance coverage inquiries and concerns with speed and professionalism through daily interaction with customers, insurance carriers, and fellow employees while conducting...

  • Registered Nurse

    4 weeks ago

    Scottsdale, Arizona, United States Salt River Pima Maricopa Indian Community Full time

    Job SummaryWe are seeking a highly skilled Registered Nurse to join our team as a Utilization Review Specialist. In this role, you will be responsible for reviewing medical information and determining medical necessity for patients. Your goal will be to balance the quality of patient care with cost efficiency to maximize the continuity of care.Key...

  • Personal Lines Insurance Coverage Specialist

    2 weeks ago

    Scottsdale, Arizona, United States NAPAA Full time

    Job SummaryThe Personal Lines Customer Service Representative at NAPAA is responsible for maintaining solid customer relationships by handling personal lines insurance coverage inquiries and concerns with speed and professionalism through daily interaction with customers, insurance carriers, and fellow employees while conducting specific service and...

  • Credit Risk Review Officer II

    1 month ago

    Scottsdale, Arizona, United States Western Alliance Bank Full time

    Job Title: Credit Risk Review Officer IIThis is a dual role position responsible for performing tasks that increase the data-driven operational successes of the department. The Credit Risk Review Officer II will develop analysis and reporting tools to evaluate and provide oversight of the bank's Concentration and Counterparty activities, controls, and...

  • Contract Review Attorney

    2 days ago

    Scottsdale, United States LegalSifter Full time

    ABOUT LEGALSIFTERContracts are the most important documents in global commerce. They are also consistently a pain. We cure contract pain with Combined Intelligence™ (AI and human expertise) delivered through software and services. LegalSifter offers products that make contracts easier both before and after they are signed.OUR STRATEGYContracts are underled...

  • Transportation Operations Coordinator

    2 weeks ago

    Scottsdale, Arizona, United States Cave Creek Unified School Full time

    Job Summary:Cave Creek Unified School is seeking a skilled Transportation Operations Coordinator to join our team. The ideal candidate will have a strong ability to support District schools and principals in their effort to foster an optimal educational environment for students. The Transportation Operations Coordinator will be responsible for monitoring...

  • Tax Operations Manager

    3 weeks ago

    Scottsdale, Arizona, United States Fortitude Family Office Full time

    Job Title: Tax ManagerWe are seeking a highly skilled Tax Manager to join our team at Fortitude Family Office. As a key member of our tax team, you will be responsible for overseeing the planning, scheduling, preparation, research, and review of federal, state, and local tax returns for both individuals and businesses.Key Responsibilities:Guide and manage...

  • Financial Operations Manager

    4 weeks ago

    Scottsdale, Arizona, United States Progress Residential Full time

    Job OverviewProgress Residential is seeking a highly skilled and experienced Assistant Controller to join our team. As a key member of our financial operations team, you will be responsible for directing the property accounting team, managing the monthly accounting close process, and ensuring timely and accurate financial reporting across the Company.Key...

  • Operations Specialist

    1 month ago

    Scottsdale, United States Robert Half Full time

    Job DescriptionJob DescriptionWe are offering a long-term contract employment opportunity for an Operations Specialist in Scottsdale, Arizona. This role focuses on overseeing operational processes, managing initiatives, and ensuring efficient project setup and management within our organization. The Operations Specialist will also serve as the primary...

  • Financial Operations Manager

    2 weeks ago

    Scottsdale, Arizona, United States Strolleria Full time

    Strolleria is a leading retailer of baby products and accessories, with a strong presence in the market. We are seeking a highly skilled and experienced Financial and Operations Manager to join our team.The successful candidate will be responsible for managing our financial and operational systems, processes, and internal controls. This will involve...

  • Financial Operations Manager

    3 weeks ago

    Scottsdale, Arizona, United States Optima Medical Full time

    Job DescriptionOptima Medical is a leading medical group in Arizona, with 23 locations and over 90 medical providers serving more than 120,000 patients statewide. Our mission is to improve the quality of life in Arizona by providing personalized healthcare services, focusing on preventing the nation's top leading causes of death. We are seeking a highly...

  • Director of Room Operations

    5 days ago

    Scottsdale, United States Marriott Full time

    Additional InformationJob Number24193259Job CategoryRooms & Guest Services OperationsLocationThe Phoenician a Luxury Collection Resort Scottsdale, 6000 East Camelback Road, Scottsdale, Arizona, United States, 85251VIEW ON MAPScheduleFull TimeLocated Remotely?NPosition Type Management JOB SUMMARY   Functions as the strategic business leader of the property's...

  • Reinsurance Operations Specialist

    3 weeks ago

    Scottsdale, Arizona, United States PRI Technology Full time

    Reinsurance Operations AnalystAt PRI Technology, we are seeking a highly skilled Reinsurance Operations Analyst to join our team. As a key member of our reinsurance operations team, you will play a critical role in ensuring the accuracy and efficiency of our reinsurance billing and cash recoveries processes.Key Responsibilities:Work closely with the Director...

  • Accounting Operations Accounts Payable Lead

    3 weeks ago

    Scottsdale, Arizona, United States Ledgent Finance & Accounting Full time

    Job DescriptionAs a key member of the Accounting Operations team, the Accounting Operations Accounts Payable Lead will be responsible for ensuring efficient day-to-day Accounts Payable operations. This includes ensuring expectations of customers and AP Department KPI's are met. The successful candidate will be hands-on as needed to keep up with work volume...

  • Financial Operations Director

    3 weeks ago

    Scottsdale, Arizona, United States Roberts Resorts Full time

    Job SummaryThe Financial Operations Director will oversee property accounting operations, ensuring accurate month-end closings and implementing robust accounting policies and procedures. This role will supervise financial reporting, support budget creation, and manage daily cash positions and accounts payable requirements.About Roberts Resorts &...

  • Accounting Operations Accounts Payable Lead

    4 weeks ago

    Scottsdale, United States Ledgent Finance & Accounting Full time

    Job DescriptionJob DescriptionAccounting Operations Accounts Payable LeadLocation: Scottsdale, Arizona(in-office during training/hybrid after training)Position overview:Reporting directly to the Accounting Operations Manager, this position is responsible for ensuring efficient day-to-day Accounts Payable operations. Ensures expectations of customers and AP...

  • Tax Operations Manager

    4 weeks ago

    Scottsdale, Arizona, United States Uplinq Full time

    Job SummaryWe are seeking a highly skilled Tax Operations Manager to lead our growing compliance team at Uplinq. As a key member of our team, you will be responsible for overseeing the preparation of complex individual and business tax returns, ensuring accuracy and compliance standards are met.Key Responsibilities:Comprehensive Tax Review and Compliance:...

  • Business Operations Manager

    4 weeks ago

    Scottsdale, Arizona, United States Malibu Events Promotions Full time

    Lead and Succeed: Business Manager NeededWe are seeking a dedicated Business Manager to oversee our company's daily activities and ensure operational efficiency.Key Responsibilities:Manage day-to-day business operations, including sales and administrative functionsDevelop and implement business strategies and sales plansOversee budgeting, forecasting, and...

  • Financial Operations Specialist

    3 weeks ago

    Scottsdale, Arizona, United States AZ TUITION CONNECTION INC Full time

    Job SummaryWe are seeking a skilled Financial Operations Specialist to support our company's financial management needs. The ideal candidate will have a strong background in accounting and a keen eye for detail.ResponsibilitiesManage and reconcile financial transactions in QuickBooksPrepare and review financial reports and statementsCollaborate with internal...

  • Operating Room Nurse

    4 weeks ago

    Scottsdale, United States USPI Full time

    Job SummaryThe Operating Room Registered Nurse provides high-quality patient care and service during surgery cases. This role requires strong clinical skills, leadership abilities, and effective communication.Key Responsibilities:Position patients for surgeryPrepare patients for surgical proceduresCirculate cases and ensure a smooth surgical...