Claims Operations Resume Samples

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D Christiansen

Dante

Christiansen

7205 Borer Wells

Boston

+1 (555) 740 6413

7205 Borer Wells

Boston

Phone

p +1 (555) 740 6413

Experience Experience

Dallas, TX

Claims Operations Oversight

Dallas, TX

Crona-Gleason

Dallas, TX

Claims Operations Oversight

Provides leadership to major projects and improvement efforts. Develops and manages project plans for projects
Proactively identify improvement opportunities based on industry and competitive trends and analysis of current processes and barriers
Leads implementation efforts and manages change to assure expected results are achieved
Knowledge of Microsoft Visio, Excel, Access, Word
PMP, CBAP, or CCP certification
Knowledge of Power Point
Knowledge of HOD Systems, SQL, MTV

Philadelphia, PA

Claims Operations Associate

Philadelphia, PA

Goodwin Inc

Philadelphia, PA

Claims Operations Associate

Performs clerical duties, including data entry, filing paper documents, email, calendar management, and word processing
Develops claim knowledge for Life, Annuity and AD&D products and applies basic knowledge to set of procedures and processes
Provides information and assistance of a general nature to leaders and employees
Provides back-up for any support functions in the office
Performs routine tasks of basic complexity under general supervision
Provides back-up for any support function in the office
Call management

present

San Francisco, CA

Director of Claims Operations

San Francisco, CA

Stamm-Murphy

present

San Francisco, CA

Director of Claims Operations

present

Performs salary administration and conducts interviews and makes recommendations for new hires, consultants and/or replacement personnel
Meets regularly with several Provider Association groups including MHA and MMS
Manage the day-to-day operational duties of Claims Operations
Interacts with the following business units on claim adjudication issues: HSN, OLTSS, Providers and Plans, Behavioral Health Unit, Program Integrity and MMIS
Responsible for the management of all suspended claims representing an average daily inventory of 25,000 claims
Monitors daily and weekly production of claims by analyzing several MMIS reports and through adhoc reporting
The Director serves on several workgroups and leads Claims Processing initiatives for the Third Party Administrator for OLTSS and several Payment Reform work groups involving the ACO implementation

Education Education

Bachelor’s Degree in Finance

University of California, San Diego

Bachelor’s Degree in Finance

Skills Skills

Excellent communication skills – writing, presentation, and verbal
Problem solving skills, creative, strategic thinker
Autonomy – can work independently and work well at all levels of an organization
Interpersonal skills
Customer focus
Eagerness to learn about the process of managing people and what it takes to be an effective leader at Kaiser Permanente
Desire to learn about the end-to-end claims administration and payment life cycle and its important role in a health plan

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15 Claims Operations resume templates

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Claims Operations Oversight Resume Examples & Samples

Bachelor’s Degree, technical area preferred, or technical training or related experience equivalent
5 years of business analysis, project, and process management experience
May substitute equivalent education and/or experience for degree
Ability to read and interpret documents such as contracts and operations manuals
Ability to develop project plans encompassing input from internal/external leadership
Problem solving abilities
Self-motivated and task oriented
Able to prioritize assignments with little guidance
Knowledge of Microsoft Visio, Excel, Access, Word
Collaborative in a team environment
PMP, CBAP, or CCP certification
Knowledge of Power Point
Knowledge of HOD Systems, SQL, MTV

Claims Operations Oversight Resume Examples & Samples

Knowledge of Microsoft Excel, Word
Claims background
Visio and Access
Knowledge of TRICARE

Senior Medicaid Claims Operations Analyst Resume Examples & Samples

Minimum 2 years of related worked experience managing and processing data, preferred
Familiarity with the pharmaceutical industry is strongly preferred
Ability to continually build detailed subject matter expertise in Government Contracting Compliance
Must be able to comprehend and/or learn complex government compliance requirements and retain, build upon and apply this knowledge on a daily basis
Experience working in mandated deadline environment and effective management of multiple client assignments
Strong written and verbal communication skills; High accuracy rate and attention to detail; Ability to work with software packages, Excel (required), and Word
Ability to produce client-ready deliverables to a high-level professional clientele and deliver required periodic results with a high degree of accuracy and minimal management review

Claims Operations Associate Resume Examples & Samples

Minimal filing
Mail support
Managing reports and information
Call management
Maintain internal and external customer relationships
Sort, distribute, and file paperwork and mail as appropriate
Good organization skills with timely follow-up skills
Military candidates encouraged to apply

Claims Operations Associate Resume Examples & Samples

Performs clerical duties, including data entry, filing paper documents, email, calendar management, and word processing
Provides information and assistance of a general nature to leaders and employees
Completes all necessary forms, logs documents into the system, and routes them to the appropriate parties
Starting salary: $31,200/yr
High School Diploma/ GED with previous experience in either customer service and/or a professional work environment ↵
Bachelor's Degree is strongly preferred
Excellent customer service skills and a passion to help others
Strong computer, typing and grammar skills
Bilingual candidates are strongly encouraged to apply
Military candidates are strongly encouraged to apply

Claims Operations Associate Resume Examples & Samples

Process, sort, index and route incoming and outgoing communications related to claim operations
Receive, screen and route telephone calls and other electronic correspondence
Starting Salary: $31,200/yr
High School Diploma/General Education Diploma (GED), plus one year of customer service experience in an office environment

Manager, Claims Operations Resume Examples & Samples

Manage and oversee expense budget planning, reporting and variance analysis including capital project costs
Develop accounting policies and processes to ensure compliance with technical accounting requirements and improve financial operations
Oversee Centene’s Sarbanes Oxley Risk Control Audit Process for the Business Operations organization,
Coordinate capital project planning, ROI and cost analysis
Serve as the liaison to the Corporate Accounting department and provide support to senior management
Analyze various data, including clinical, financial, health care outcomes, claims, and encounters, ensuring data integrity and establish financial models/reports to track key financial and volume metrics
Identify data trends and recommend improvement opportunities to reduce cost and improve processes
Manage various research and development projects and assess business needs for improvement initiatives

Associate Director Facets Claims Operations Resume Examples & Samples

Conduct business process analysis to identify key business needs, issues and / or gaps and leveraging Optum partners build solutions for flawless Claims operations execution
Work closely with partners including Business Analyst and IT teams to identify requirements to support the process and service solutions
Ensure buy - in of proposed solutions from key product owners, operational and technology partners and leadership
Work collaboratively with the business partners and UAT team to provide guidelines to develop test case scenarios
Act as Facets SME
Collaborating with other work stream partners, provide direction on priorities of process deliverables
Provide timely written and / or verbal communications regarding process progress including deliverables, significant milestones, risks and mitigation strategies to the management team
Manage project risks and issues, adhere to project timelines
Ensure timely and effective execution of all deliverables
Support RFP design and development as needed to ensure end to end delivery is well thought through for quality execution
5 + years’ experience in leading operations and / or business process improvement development and execution initiatives, integrating the voice of the internal and external constituents, preferably with a state Medicaid program
3+ Years of experience working in Facets Claims
Medicaid experience
Facets (platform) experience
Experience and working knowledge of CA Agile Central (formerly known as Rally)
Bachelor’s degree in Business, Finance, Health Administration, related field or equivalent work experience

Claims Operations Manager Resume Examples & Samples

Oversee daily operations of multiple levels of staff and multiple functions across one or more business units
Manage day to day site operations, supervisor leadership (internal and external to organization), and accountability for financial and non-financial results (budgets and actuals)
Provide expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
Authorize the appropriate payment or refers claims to investigators for further review
Conduct data entry and re-work; analyzes and identifies trends and provides reports as necessary
Lead project management and implementation initiatives
Proven ability to lead multiple teams and priorities
3+ years of Supervisory/Managerial experience in Claims Adjudication or Customer Service
2+ years of experience managing relationships with clients and/or vendors
2+ years of experience managing budgets, process improvement and quality assurance
Undergraduate Degree (or higher)
5+ years of healthcare claims leadership experience
2+ years of experience developing presentations to include charting
Understanding of claims processing systems
Senior Level Supervisory/Managerial experience in medical claims

Claims Operations Associate Resume Examples & Samples

This life insurance / annuity claims related role will involve approximately 30% of the time on the phone with callers (policyholders, beneficiaries, agents, etc.) and 70% of the time processing claims support work (claims research and system updates)
Develops claim knowledge for Life, Annuity and AD&D products and applies basic knowledge to set of procedures and processes
Completes a variety of assignments (typically recurring tasks and standardized activities)
Position involves use of established tools and procedures to solve task-related problems including: Fact finding, information research and gathering, verifying and compilation of data
Regular contact with customers via phone inquiries
Monitors and tracks resolution of issues. Recognizes when there is insufficient information and brings problems to the attention of others
Organizes and completes tasks according to assigned priorities
Position requires an 8-5 Mon-Fri schedule

Manager, Claims Operations Resume Examples & Samples

Direct experience with payor
Direct experience with 3rd party claims vendor
Knowledge of claims systems
Self starter, motivated
Hands-on, organized, efficient

Claims Operations Associate Resume Examples & Samples

Work involves routine problems of limited scope and use of established guidelines, policies, procedures, methods or protocols
Learns to use professional concepts and company policies and procedures to solve routine problems
Work is reviewed and guidance given by supervisor or more senior members of team
Experience in claims, coding, billing or other experience in workers' comp/health plan/insurance
Claims and provider work experience preferred

Claims Operations Associate Resume Examples & Samples

Handles claim files (locates/requests files, files paperwork, reconstructs missing files, moves misfiled documents, sends to other offices, etc.)
Retrieves, prints, faxes, or mails supporting documentation to vendors or others as directed
Provides back-up for any support functions in the office

Associate Director, Claims Operations Resume Examples & Samples

Collaborate and validate in the development and completion of key deliverables and client metrics
Develop and facilitate Communication Plans for onsite delivery teams and CTS leadership
Guides each work stream in team structuring and building
Gain consensus on baseline performance with key stakeholders
Updates client executives weekly on progress of each workstream
Hold crucial conversations with team members and customer to ensure engagement success
Facilitate the identification of process inefficiencies via root cause, and elevating issues and barriers to transition head & leadership and region as needed
Validate the established goals for targeted workstreams
Assist in the identification of additional improvement opportunities
Monitors transition and financial metrics, deliverables and adjusts solutions to de-risk any issues to operations
Perform any other job related or client-relationship-building metrics as needed
Managing ambiguity and challenging client situations with excellence and diligence
10+ years of experience in healthcare claims and configuration
5+ years of experience in operations and management

VP, Claims Operations Resume Examples & Samples

Responsible for the review and settlement of complex or high dollar claims
Develops procedures and policies to enhance and improve the processing, investigation, and settlement of claims
Quality management of claims, service delivery to customers, claim resolution and jurisdictional compliance
Provides guidance and direction to Regional Claim Directors and Claim Supervisors through a continuous process of management involvement and claim file review
Assists with the development and implementation of claim management strategies consistent with corporate best practices
Participates in the selection, development and evaluation of the assigned claim team members
Manages staff performance; implements strategies and plans to address staff development; identifies and address training needs on an ongoing basis; provide frequent performance feedback
Provides advanced technical leadership focus to strengthen the technical development of the staff
Communicates regularly and effectively with staff, both as a team and individually
Effectively uses management information reports and analyzes claim data to identify business drivers and trends
Must possess or be able to obtain adjuster licenses in all applicable states
Insurance professional designation preferred (AIC, CPCU, SCLA)
Leadership: a demonstrated ability to lead people and get results through others
Planning: an ability to think ahead and plan over a 1-2 year time span
Management: the ability to organize and manage multiple priorities
Problem analysis and problem resolution at both a strategic and functional level
Strong customer orientation
Excellent interpersonal and communication skills including presentation skills
Ability to develop high performance teams and be a strong team player
Minimum ten years insurance experience handling auto and casualty claims. Experience handling non-standard auto insurance claims is preferred
Minimum five years’ experience managing others in a claims environment

Director of Claims Operations Resume Examples & Samples

Oversees the Maximus, the Customer Service Contractor with the receipt of several electronic transactions including HIPAA claim transactions 837P, 837I and 90 day waivers, and Direct Data Entry of Paper claim submissions
Oversees the Suspense Resolution Unit at MassHealth whose analysts are responsible for reviewing and pricing claims that require manual review including all suspect duplicate claims submitted by Hospitals, Medical providers and Nursing Facilities
Responsible for the management of all suspended claims representing an average daily inventory of 25,000 claims
Directs the activities of 15 claim analysts with the adjudication of MassHealth and HSN claims
Oversees the maintenance of the MMIS reference file which includes the updating of all provider class rates for 60 programs, and the management of all 1,200 MMIS edits and claim audits
Oversee the Final Deadline Appeal Unit at MassHealth whose analysts are responsible for reviewing and making the final determination of claims submitted by providers
Participate in MMIS testing and approval of all production releases
The Director serves on several workgroups and leads Claims Processing initiatives for the Third Party Administrator for OLTSS and several Payment Reform work groups involving the ACO implementation
Responsible for resolving claim payment escalations received from Program and the Customer Service Contract staff
Interacts with the following business units on claim adjudication issues: HSN, OLTSS, Providers and Plans, Behavioral Health Unit, Program Integrity and MMIS
Monitors daily and weekly production of claims by analyzing several MMIS reports and through adhoc reporting
Meets regularly with several Provider Association groups including MHA and MMS
Manage the day-to-day operational duties of Claims Operations
Decides staffing requirements for projects and operations
Extensive knowledge of MassHealth and claims processing
Knowledge of the principles and best practices of claims submissions
Ability to analyze data and determine the applicability of data, to draw conclusions and make appropriate recommendations
Ability to supervise, including planning and assigning work according to the nature of the job to be accomplished, assess the capabilities of supervisees and available resources
Ability to assist in the development of new or expanded MassHealth services
5 years of previous managerial experience
At least 2 years of project or program management experience, preferred
Strong effective communication skills
Excellent interpersonal and coaching skills
Excellent problem resolution and negotiation skills
Ability to manage, evaluate and motivate staff
Ability to work independently and manage multiple priorities effectively
Ability to manage a broad array of projects simultaneously and to respond to changes in goals or priority in a flexible manner
Strong customer service orientation and focus
Excellent computer skills in Microsoft Windows environment
Excellent writing skills, including the ability to present complex and technical information clearly and concisely
Excellent presentation skills, including the ability to lead information and training sessions with municipal education program representatives and health care providers
Ability to work with a wide variety of people and to establish and maintain effective working relationships
Excellent quantitative and qualitative analytical skills using tools like Microsoft Excel
Ability to manage time, to set priorities, and to work under time constraints
Knowledge of and experience in health care policy and financing
Knowledge of general, statistical and technical report writing, the ability to write clearly and concisely and to communicate effectively
Ability to analyze and determine the applicability of financial and program data, to draw conclusions, and to make appropriate recommendations
Ability to maintain accurate records, to exercise sound judgement, and to handle confidential material

Claims Operations Manager Resume Examples & Samples

Works on issues of diverse scope
Receives assignments as objectives and determines how to use resources to meet these goals and schedules
Requires significant planning and direction setting to coordinate with other divisions or resources
Recommends changes to policies and establishes procedures that affect the immediate function
Monitors projects to ensure completion on schedule and within budget
Minimum three (3) years of lead or supervisory experience in a claims processing environment
Experience in LMP environment managing large groups of employees in a collaborative work team environment required
Five (5) years of management experience

Head of Claims Operations Resume Examples & Samples

Experienced in all aspects of casualty claims management (claims investigation, litigation management, return to work strategies, Workers Compensation statutory requirements, medical cost containment strategies, etc.); US legal and regulatory constructs; operational risk assessments and mitigation strategies; analytical insights to solve complex situations and drive fiscally beneficial solutions
Demonstrated thought leadership: strategic thinking and ability to set priorities / objectives on a national scale, ability to influence at all levels of the organization, exceptional communicator; articulates thoughts and ideas clearly
Highly skilled people leader and change agent: creates a climate of collaboration to deliver results, removes barriers that prevent people from working effectively, engages the right people across the organization, keeps them apprised of changes
Professional insurance designations such as Certified Professional Commercial Underwriter (CPCU), Associate in Risk Management (ARM). Minimum of 10 years of relevant work experience

Manager Claims Operations Resume Examples & Samples

Diploma in Insurance or equivalent NQF level 5 qualification and studying towards NQF level 6 (IISA)
Five (5) years experience in Short Term insurance which includes Commercial and Industrial insurance
Three (3) years experience in managing a team of managers
Experience in applying claims cost control principles

Director Claims Operations Resume Examples & Samples

Oversee management team to identifying cost containment, audit and recovery opportunities with provider payments
Manage the inventory of Claims to meet with all Blue Cross and regulatory guidelines
Manage the Coordination of Benefits and integrate to all forms of input including, Web, Paper and phone
Direct staff to manage accurate and cost effective benefit administration and timely processing of all claims and member inquires
May recommend changes in claims processing and coordination of benefits procedures
Direct a staff that may be directly involved in complex claims audits
Minimum of 10 years of experience in the credentialed field or in a health care or business related discipline
Excellent communication skills, both oral and written; and strong analytical skills
Proven strategic planning skills including the ability to create, drive, and implement the development of an effective long term strategy
Excellent interpersonal and leadership skills to interact with direct and indirect reports

Administrative Assistant, Claims Operations Resume Examples & Samples

Minimum typing skills of 30 WPM with accuracy of 95% required
Must exhibit and use good verbal and written communication skills
Good organizational skills and attention to detail required

Claims Operations Manager / EDI Resume Examples & Samples

Manage reconciliation of EDI files (compliance reporting, claims, authorizations, etc.)
Financial processes for check runs
Manage Claims adjudication audits
3+ years of experience with direct people management in an Operational role
Manage overall quality, productivity and outcomes of medical/healthcare claims processing team in a Service Level Agreement environment
Manage day to day operations of multiple groups (including Mail Room, ANSI 837, Financial, Quality Assurance, Claims Processing)
Direct management of employees including performance, adherence to policy, handling Protected Health Information
Lead customer calls to resolve questions or inquiries
Manage costs to budget
Handle issues or escalations from Call Center or from the Client
Participate or lead a Six Sigma process improvement project
Excellent oral and written communication skills including formal presentations to a variety of audiences – technical, business and executives
Experience using Microsoft Office tools including Outlook, PowerPoint and Excel
Demonstrated capacity to work with others to coordinate activities and achieve goals
Ability to be self-directed and results oriented
Ability to manage a number of tasks in an organized and efficient manner
Direct experience with communicating with clients
Direct experience with 3rd party claims vendors
Knowledge of ICD10/CPT codes
Knowledge of medical claims adjudication and financial/payment systems
Excellent communications skills (oral and written)
Self starter, motivated, Hands-on, organized, efficient
Strong Project Management skills demonstrating the ability to handle multiple priorities
Six Sigma knowledge a plus

Claims Operations Lead Resume Examples & Samples

Develop, implement and maintain an effective and efficient model and team for the delivery of high quality claims operational support to the region, including the most efficient and effective deployment of resources to accomplish goals
Lead the North America Claims Operations team supporting the region, including providing performance management, quality review, and day-to-day guidance, training and mentoring in support of colleagues’ professional development
Establish, document and maintain a catalogue of mutually agreed claims technical support services, including business processes, procedures and service level agreements (SLAs) for the provision of those services
Develop a metrics framework for measuring the performance of the Operations team against agreed upon SLAs and other standards of performance
Serve as primary point of contact and liaison with other Global Claims Operations teams supporting North America Claims and non-claims functions to ensure alignment (e.g., Shared Services, Claims TPA/Delegated Authorities, PMO, Quality Assurance, Underwriting, Claims Legal, Accounting, Finance, Tax, Compliance, etc.)
Support the Global Claims Operations group in the maintenance of the Global Claims Business Process Narrative, which describes processes and key controls, and ensure the North America staff is fully aware of and appropriately executing those processes and controls. Serve as North America liaison with Internal Audit, Financial Internal Control (“FIC”), and company’s auditors in their review of business processes and control testing, collaborating with the Global Claims Operations group as appropriate
In alignment with the Global Claims Operations function, lead change and maintain a culture of continuous improvement in North America Claims Operations, identifying opportunities to more effectively or efficiently execute on services and agreed solutions. This includes, but is not limited to partnering with our Global Operations Project Management Office on regional work streams to plan, develop, and deliver change across the North America region
Support the North America Claims Chief of Staff and Head of Claims Operations and Global Claims Operations by taking a leading role in the planning, coordination and implementation of regional Claims operational plans and activities, including the annual planning and budgeting process
Manage vendor relationships, ensuring the delivery of services in accordance with established standards of performance
Act as the principle liaison and take a leading role with offshore Claims Shared Services support teams, including work prioritization, transition planning and work balancing
End User Support – coordinate new hire system training and serve as main point of contact for all end user system access and support inquires. Serve as liaison between business and technology for feedback and suggestions on system enhancements and business process improvement opportunities
Education: Bachelor's degree required; Insurance certifications (AIC, CPCU, ARM or similar) a plus
Experience: 10+ years of insurance industry operational/shared services support experience. Preferred direct experience in managing centralized groups and teams – remote and on-site staff
Analytic Skills: Possesses strong analytical skills and sound judgment
Leadership: Role model by setting a high bar for performance, engagement and commitment. Ability to coach, develop, set expectations, evaluate and hold people accountable for delivering. Takes initiative and has the ability to lead independently. Able to effectively lead change
Strong Communication: Excellent verbal and written communication, collaboration, presentation and influencing skills. Able to communicate effectively with internal and external stakeholders at all levels of sophistication
Agility and Flexibility: Ability to work in a fast-paced environment and efficiently juggle numerous concurrent responsibilities
Collaborative approach: Develop and maintain productive working relationships with internal and external colleagues and staff. Provide guidance and seek input from others as needed to achieve the best result possible. Capable of working and collaborating with a virtual team
Results Oriented: Approach tasks proactively and anticipate needs. Think quickly and prioritize multiple work streams without sacrificing quality. Act with a sense of urgency
Continuous Improvement Focused: Willing to ask questions and explore new ideas. Eager to learn and focused on continuously improving technical skills and XL Catlin claims capabilities
Client-Service Oriented: Focused on value at all points in the claims experience delivering on our promise to internal and external clients

Claims Operations Associate Resume Examples & Samples

Minimum of 2 years of customer service experience in a professional work environment
Experience using Excel and Word is a plus
Must be able to lift 10lbs/office equipment

VP, Regional Claims Operations Resume Examples & Samples

Develops strategy for regional claims offices and implements plans to improve claim performance and control costs. Prepares and operates within budget. Utilizes broad LOB knowledge to provide technical expertise to regions, Underwriting and other areas within the organization
Plans, controls and coordinates claims activity and workflow in order to maintain the highest professional customer service and technical standards. Ensures claim settlement is in compliance with company guidelines across all regions
Directs procedural changes and plans to increase efficiency and effectiveness of claim handling
Maintains override capability, authorizes settlements up to designated authority limits, and submits recommendations to senior management for those claims in excess of authority level
Oversees and controls allocated claims expenses. Oversees combined loss ratio and productivity numbers for all regions and ensures they are in compliance with company standards
Ensures effective coverage determinations, negotiations, reserving and settlement. Develops excellent working relationships with Underwriting and other lines of business
Authorizes settlements up to designated authority limits, and submits recommendations to designated officials for those claims in excess of authority level
Plans, reviews and conducts claims reviews and settlement conferences
Mediates complaints and disputes regarding claim resolution
Provides effective direction and leadership while, coaching, training and developing staff
Travel: 1to 2 weeks per month. Company car provided
Must have proven leadership skills and a successful track record in developing and managing people
Must have an ability to analyze claims data, identify claims trends, and develop a strategic response
Highly customer focused with excellent presentation and communications skills
Must possess strong organizational and project management skills, with the ability to deliver on multiple priorities
Must have excellent networking and relationship building skills and the ability to interact with confidence at all levels and functions within the organization
10+ years of claim experience in the designated line of business (WC, Liability, Auto/Property)
Strong leadership, operational and analytical skills. Must be able to proactively identify barriers to performance and act timely to remove. Must have strong leadership presence with the ability to drive a large, highly dispersed organization to execute in a consistent manner. Must be able to drive the organization to deliver high levels of customer experience

Claims Operations Resume Examples & Samples

Excellent communication skills – writing, presentation, and verbal
Interpersonal skills
Autonomy – can work independently and work well at all levels of an organization
Problem solving skills, creative, strategic thinker
Eagerness to learn about the process of managing people and what it takes to be an effective leader at Kaiser Permanente
Desire to learn about the end-to-end claims administration and payment life cycle and its important role in a health plan
Advanced analytical and problem-solving skills

Claims Operations Manager Resume Examples & Samples

Closely monitors and leads ongoing review of Claims metrics, performance, improvements, and issues with business partners and Claims teams
Works closely with the UHC Operations Business Partners and cross functional teams to accomplish organizational goals and meet contractual needs as defined by the state contracts
Serves as the primary contact with the health plans and business partners on the implementation of new or expanding business
Conducts root cause analysis on claims that contribute to decrease in performance and failure to meet commitments to understands reasons for not meeting state requirements, as well as developing action planto address the issues / gaps with the cross functional teams
Develops and executes plans to improve existing performance and efficiency in operational processes
Leads large, complex projects to achieve key business segment objectives
Oversees the operational aspects of new product implementations to ensure operational contract compliance
Oversees the operational aspects of new site start - ups to support in state requirements for new or expanding business
Monitors performance results and works with the cross functional teams to address gaps in performance
Provides support and coordinates with UHC Benefit Operations for any Claims needs in audits or regulatory inquiries
Delivers executive level presentations and summaries, driving corrective actions based on operational results and develops / enhances business policy to align with regulatory programs
Responsible for operational management, meeting our commitments, supporting strategy development for the group and enhancing our capabilities
4+ years of experience with large scale, complex operations, that includes managing and driving large scale team performance
4+ years of leadership experience with increasing responsibility, in a growing environment with continuous build out of processes
Intermediate or higher level of proficiency with PowerPoint, Excel, Word, SharePoint, and Outlook
Up to 10% trave
Medicaid, Medicare, Long Term Care and / or government health plan experience
Health insurance experience
Experience working in a fast pace, production environment, with focus on important business deadlines
Proven problem solving skills and ability to translate knowledge to the operations
Proven ability to influence course of action when others are directly accountable for outcomes
Ability to manage multiple tasks and priorities in a matrix environment, strong problem solving skills and attention to detail
Demonstrated ability to interface and present to senior management effectively
Excellent collaboration, drive for results and organizational excellence
Excellent communication (both written and verbal) skills

Admin Assistant, Claims Operations Resume Examples & Samples

10. Must have regular predictable attendance
Must be familiar with operation of general office equipment
Minimum one (1) year experience in a similar job which included customer service

Head of Liabilities Claims & Claims Operations Resume Examples & Samples

Develop and implement claims policies, procedures, objectives and standards and also establish settlement authority for Liabilities Claims
Accountable for the business results of US Claims (Both PSR & LFL), including overall budget, staff management and compliance activities
Attract and retain business by marketing AIG Claims capabilities and maintaining relationships with strategic external business partners
Provide technical leadership to Liabilities senior management regarding issues of risk selection, policy language and reserve adequacy pricing book of business, and apprise senior management of changes/ trends in the legal, regulatory and claims environment
Accountable for the overall organizational leadership, employee engagement and internal communications
Identify succession plans on all direct reports through development opportunities, recruiting, sourcing or internal appointment including achieving corporate diversity objectives
Cascade guardrails and tailor global best practices for accurate reserving, investigation, and disposition of claims for LoBs
Collaborate with CCO to develop guardrails on processing of product-specific express claims
Control product-specific Claims budget, as set by CCO
Delegate claims authorities for Express, Complex, and Major Loss CoEs
Ensure that LoB strategy aligns with global strategy
Oversee execution of LoB strategy and team within Major Loss CoE
Global coordination of Claims within products
Cascade caseloads for LoB and CoEs and agrees on headcount relative to the model (in collaboration with CCO and country GMs)
Direct or conduct annualized multi-line operational, technical and service audits in all countries
Act as internal claims consultant for exceptional cases
Ensure consistent customer service levels globally; interface with key customers, as needed

Manager, Medicare Claims Operations Resume Examples & Samples

Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims and encounter processing and provider inquiries (written or verbal)
Assure timely and accurate processing of Medicare claims and encounters, and respond to provider telephone calls, written inquiries, and appeals
The compilation of all information and documents required for claims and encounter processing and related inquiries to assure compliance with all applicable rules, regulations, and external and internal policies and procedures
The review of provider contracts and configuration of these contracts within the claims processing system to assure accurate payments to our providers
Collaboration and communication with other SHP departments on claims and encounter issues, related projects and inter-departmental operations issues
Development and maintenance of well-defined processes to enter, adjust, manage and report claims and encounters data
Preparation and timely submission of management and regulatory reports
Generation of configuration requests to assure accurate, timely administration of providers claims and processing and reporting of encounters
Maintain a full comprehensive understanding of the covered benefits, coding and reimbursement policies and contracts
Production and submission of reports as required
Analyze, track and trend claims and encounters data; identify any potential service or systems issues; implement interventions, and determine success of intervention
BA/BS degree preferred with at least five (5) years of relevant professional experience, and the following OR any combination of education and experience which would provide an equivalent background
3 years of managerial experience at the department supervisor/manager level preferred
4 years of Medicare/Medicaid claims experience required
Extensive knowledge of claims policies and procedures, including industry standards from Medicaid, CMS, and CCI Edits
Excellent oral and writing skills

Claims Operations Specialist Resume Examples & Samples

Reads, analyzes, interprets and explains insurance policies and Roadside Assistance endorsement
Communicates effectively to resolve complaints, concerns and questions regarding Roadside Assistance
Reviews pending work on a regular basis and makes contact with insureds, agents and vendors to determine progress and communicate status. Reviews concerns with supervisor on a regular basis
Reviews, evaluates and monitors data for the Roadside Assistance program to identify opportunities for improvement and ensure a successful program
Serves as a resource for problem identification and resolution, exercising considerable discretion in selecting and implementing solutions. Escalates identified issues through Claims Management to resolve problems. Provides support on workflow processes and functionality of Claims Systems
Coordinates development of Claims forms and letters and serves as department resource on forms and letter issues. Serves as Claims Department representative on Company Forms Committee
As part of the Home Office Catastrophe team, maintains employee information and activates Claims Assistants as requested. Thorough knowledge of Catastrophe workflow to assist in performing a variety of tasks
Oversees Debit Card program. Monitors usage of cards and helps maintain debit card spreadsheet. Manages a variety of tasks including debit card monthly bank reconciliation
Responsible for high priority workflow items including: verification of claims, adding coverages, adjusting payments and changing loss dates
Other duties may be assigned to meet ongoing business needs
Ability to perform essential functions of the job, with our without a reasonable accommodation
Educational background equivalent to a full course of study at college level with emphasis on business courses, or equivalent combination of education experience
Ability to research, analyze and make decisions for the purpose of processing nonroutine claims data
Claims department experience and detailed knowledge of department policies, procedures and operations
Superior interpersonal skills required to develop and maintain good working relationships with all areas of the Claims department, other departments and external customers
Requires excellent investigative and communication skills
Superior analytical, decision making, negotiation and customer service skills are required
Must be able to work independently, manage time effectively, maintain schedules and meet deadlines

Delegated Authority Claims Operations Analyst Resume Examples & Samples

Gap analysis. Check adherence of received bordereaux against the Lloyds standard
Bordereaux Receipt Management. track inbound bordereaux and chase for missing data
Mapping, Validation & Data Extracts. Once the bordereaux is received, ensuring that the data is mapped correctly and can be reported upon and provide corrective feedback to Coverholders and TPAs
Analyse bordereaux documenting findings on data gaps in a consistent manner
Work with the Gap Analysis Coordinator on project tasks delivering in the timescale established
Attend meetings with UKI Claims to effectively communicate data gaps to them and to coverholders / TPAs and agree a suitable communication strategy for them
Work with the service provider and UKI Claims to ensure that the mapping frameworks created are correct for the bordereaux received
Track and monitor bordereaux received from Coverholders and TPAs, flagging gaps and discrepancies with UKI Claims where appropriate
Escalate concerns to management as needed
Strong understanding of the Lloyd’s Coverholder Reporting Standards User Guide
Prior successful experience in project work in the insurance industry
Strong business engagement skills
Strong working knowledge of Microsoft Office
Experience with delegated underwriting authorities ideally within the Lloyd’s market
An in depth knowledge of commercial insurance is a plus
Reporting skills. E.g. data analysis, data integration, MI development (producing reports etc), interpret data, interpolate data, advance Excel skills (macros, VBA etc) MSAccess
Claims adjusting experience (desirable) or at least an understanding of claims language
Excellent communication skills as there will be a high degree of engagement with Coverholders, Brokers, TPAs, Underwriters and claims staff
High level of collaboration skills
Working in challenging environment so tenacity and perseverance is a must
Planning and execution skills
Ability to prioritise work and self-organise for demanding workloads and timetables

Head of Liabilities Claims & Claims Operations Resume Examples & Samples

Collaborate with the President LFL to develop guardrails on processing of product-specific express claims
Control product-specific Claims budget, as set by the President LFL
Cascade caseloads for LoB and CoEs and agrees on headcount relative to the model (in collaboration with President LFL and country GMs)

Claims Operations Specialist Resume Examples & Samples

Minimum of 24 months experience in Tufts Health Plan or THP-NH
Claims or Customer Service position preferred
Systems such as Monument (THP-NH Application), CCMS, Burgess and, On Base (to view claims imaging and processing software)
Experience with various internal systems such as), , preferred. A thorough understanding of CPT, ICD-9, and HCPCS coding guidelines and medical terminology is preferred
Ability to demonstrate understanding and proficiency of all claims concepts strongly preferred

Senior Claims Operations Manager Resume Examples & Samples

Acts as “chief of staff” for Vice President of Claims Field Operations, No Fault
Recruiting, developing, leading and directing the work of a remote team ( 2-7 Ops Managers)
Works closely with VP to define the short and long term strategy for the organization
Works closely with other teams within claims to mobilize resources, gather stakeholder buy in, drive initiatives and troubleshoot problems/crisis management within No Fault / SIU Field Org
Works with Finance to understand expense and staffing gaps for field organization, identifies drivers, develops plans and coordinates execution across the field organization to achieve targets
Works with Analytics team to understand internal and external causes of operational variances in loss results. Identifies drivers of internally driven variances, develops plans to address loss gaps. Manages execution across the field organization
Primary contact for HO stakeholder groups (Product, Strategy/Analytics, Technology, Compliance, Complaints, etc.) on behalf of field org for all initiatives that may impact the field organization (product changes, CX initiatives, productivity improvement efforts, annual plans, pure premium improvement plans, operating budget, staffing, etc.)
Collaborates with Analytics team to understand office and individual performance, and in partnership with HR, works to ensure effective and calibrated interim reviews, final reviews and talent review
Represent No Fault / SIU Field Org on cross functional teams where appropriate
Monitors quality control inspections and programs in region, including market conduct exams and internal audits
In conjunction with Field Management, ensures branch office compliance with existing policies, procedures, and regulation
May assume responsibility in the VP or Field Manager’s absence
Participates in the annual planning process, LMS and continuous improvement initiatives
Leads, guides and/or completes special projects, as required
Approximately 25-40% travel required
Bachelor's degree, or equivalent work experience plus at least 10+ years of progressively more responsible experience required. Prior management experience desired
Ability to organize, lead and get work done through others; in depth knowledge of insurance products
Advanced analytical skills to interpret business information drawn from multiple sources to make critical decisions
Demonstrated team management skills and abilities
Effective interpersonal skills needed to create and enhance partnerships with internal and external customers; including verbal and written communications