Resp & Qualifications

We are seeking an experienced and dynamic Claims Operations Director to join our team and oversee our claims management organization. This position offers an exceptional opportunity to contribute to one of the largest health plans in the Mid-Atlantic region, where your expertise will play a crucial role in enhancing the quality and efficiency of our claims processes.

The Director of Claims Operations has overall responsibility and accountability for effectively and efficiently leveraging staffing, technology, and vendor relationships to lead claims processing and service operations. Establish the strategic direction for the claims business unit, integrating various components of the operation to achieve developmental and organizational goals. By fostering operational excellence and optimizing resources, the role ensures the delivery of accurate, timely, and compliant claims services that align with regulatory standards and organizational objectives.

PURPOSE:
Leads, manage and empowers operations teams to meet and exceed business delivery. Serves as a strategic leader of multifunctional teams and support roles. Oversees activities of an internal function that provides operational/business process support to internal and external customers with various carrier products. Ensures quality service and operational performance within the parameters of program and delivery standards are achieved. Analyzes operational processes, establishes escalation procedures and oversees training needs assessments to identify opportunities for service delivery improvements. Selects, develops, and evaluates employees to ensure efficient operation of the function. Leads a team of managers to manage operations support teams.

ESSENTIAL FUNCTIONS:

Develops and optimizes consistent, repeatable and measurable processes to quickly adapt to changing business conditions. Leads projects that are important to the team related to process improvement.
Develops customer support strategies, guidance, processes, metrics, reporting and technology that transform the consumer experience and support company growth
Accountable for the performance of multiple teams within a related function. Provides leadership and direction through managers.
Uses data to add value to the customer's operation and look for opportunities to recommend new products/services as appropriate
Designs and launches critical programs to improve customer experience and operational efficiency.
Develops an understanding of customer experience in all customer support interactions that occur and build to meet/exceed customer expectations.
Used data to drive decision making strategy alignment with regulatory requirements and corporate goals.

QUALIFICATIONS:

Education Level: Bachelor's Degree, Business Administration, Healthcare Administration or related discipline OR in lieu of a Bachelor's degree, an additional 8 years of relevant work experience is required in addition to the required work experience.

Experience: 8 years' experience in health insurance, call center, claims and/or enrollment and billing environment,3 years' experience in managerial functions in a customer service, claims and/or enrollment and billing or related field.

Preferred Qualifications:

5 years of Medicare Advantage and Maryland Medicaid experience.

Knowledge, Skills and Abilities (KSAs)

Must have extremely strong analytical and problem-solving skills, and the ability to develop and implement policies and programs that will advance corporate and operational goals and objectives.
Excellent planning, problem solving, presentation, written and oral communication skills are required. Excellent interpersonal skills, the ability to effectively manage a staff through leadership and the promotion of teamwork is essential.
Must possess excellent interpersonal skills and highly developed written and oral communication skills to effectively convey complex and detailed concepts to a diverse audience.
Must possess extremely well developed organizational and prioritization skills., Advanced
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $129,440 - $240,273

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Medicare/Medicaid Administration

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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