Gold Coast Health Plan
Senior Manager, Operations
Gold Coast Health Plan, California, Missouri, United States, 65018
Overview
Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges. Working at Gold Coast Health Plan means collaborating with a team reshaping how health, health care, and social services and supports are met. We are seeking collaborators, innovators, and those who are driven to be their very best. If you are seeking a career of purpose and are passionate about impacting society's health care challenges, Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure. Position Summary
Responsibilities
Lead and direct the claims management process, driving best practices to achieve high efficiency and accuracy.
Ensure processing of claims payments adheres to regulatory requirements and that payments align with benefit and contract terms; work to minimize pended and adjusted claims.
Ensure effective and efficient operational processes and regulatory adherence, including validation that new policies and procedures are implemented.
Provide subject matter expertise in project management and related areas.
Lead, coordinate and complete operational improvement projects across functional areas within and outside Gold Coast Health Plan.
Own end-to-end process improvement, including definition of need, project plans, status updates, reporting, and results.
Establish operating metrics and scorecards to manage ongoing operations.
Enhance procedures, systems, and principles in information flow, business processes, and management reporting.
Develop collaborative relationships with business partners and matrixed vendors to execute day-to-day operations.
Inform management of California Department of Health Care Services trends to support short- and long-range plans.
Oversee system conversions where applicable and coordinate with stakeholders on operational changes.
Identify and resolve technical, operational, and organizational problems inside and outside the health plan.
Lead teams to resolve cross-functional business problems and foster teamwork and inclusion.
Drive high-quality execution and operational excellence by providing clear direction and expectations.
Review and approve workflows and documentation for all claims-related functions and projects, ensuring completeness and accuracy.
Monitor delegated entities for claims compliance from regulatory and contractual perspectives.
Prepare materials for internal and external regulatory audits and legal requests.
Address escalating claims issues from providers and members to facilitate timely and courteous resolution.
Manage, develop, and lead staff; build an effective team with appropriate staffing and development.
Translate strategic goals into operating and resource plans.
Coordinate and supervise operational analyses and implementation support on major workflow and claims system modifications.
Act as a consultant to senior management on reimbursement methodologies, regulatory requirements, and claims processing protocols.
Collaborate with recovery vendors to identify funds paid in error and report recoveries.
Manage and develop the annual budget for the claims department.
Maintain external contact with regulatory agencies, providers, delegated entities, community-based organizations, and other health plans on issues related to grievances and appeals.
Minimum Qualifications
Education & Experience:
High School graduate or GED; 8+ years of professional-level experience in a claims processing department as a manager, preferably in a Medi-Cal/Medicaid managed care plan.
Excellent understanding of claims regulatory requirements including AB1455, AB97, COB, and clinical editing (NCCI).
Knowledge, Skills & Abilities
Preferred Qualifications:
Bachelor’s Degree (four-year college or technical school).
Prior experience with Meditrac claims processing system, Optum CES, Easy Group, and MHK.
Analytical ability, judgment, and problem solving with the ability to present complex information clearly.
Ability to interpret and revise policies and procedures; develop operational goals and service levels.
Maintain knowledge of the health plan’s benefit structure and manage projects to optimize resources.
Develop cooperative working relationships, select and develop staff, and operate in a fast-paced, performance-oriented environment.
Prepare clear written materials and maintain confidentiality of sensitive information.
Computer Skills Advanced computer skills in MS Office products, including Access.
Certifications & Licenses A valid and current Driver's License, Auto Insurance, and professional licensure(s).
Competencies
Management, Business Acumen, Decision Making, Goal Orientation, Interpersonal and Diversity Awareness
Time Management, Consensus Building, Relationship Building, Presentation Skills
Delegation, Leadership, Ethics, Judgment, Communication (Oral & Written), Problem Solving
Physical Demands O (Occasionally) up to 33% of the time; F (Frequently) 33%-66%; C (Constantly) >66%. Stand, Walk, Sit, Manipulate, Reach, Grasp, Lift 10-20 lbs, Carry 10-20 lbs as indicated.
Work Environment Office work environment.
Compensation The estimated pay range for the position is $142,000.00 - $213,000.00 for California. Pay range varies by location, experience, and internal pay bands.
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Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges. Working at Gold Coast Health Plan means collaborating with a team reshaping how health, health care, and social services and supports are met. We are seeking collaborators, innovators, and those who are driven to be their very best. If you are seeking a career of purpose and are passionate about impacting society's health care challenges, Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure. Position Summary
Responsibilities
Lead and direct the claims management process, driving best practices to achieve high efficiency and accuracy.
Ensure processing of claims payments adheres to regulatory requirements and that payments align with benefit and contract terms; work to minimize pended and adjusted claims.
Ensure effective and efficient operational processes and regulatory adherence, including validation that new policies and procedures are implemented.
Provide subject matter expertise in project management and related areas.
Lead, coordinate and complete operational improvement projects across functional areas within and outside Gold Coast Health Plan.
Own end-to-end process improvement, including definition of need, project plans, status updates, reporting, and results.
Establish operating metrics and scorecards to manage ongoing operations.
Enhance procedures, systems, and principles in information flow, business processes, and management reporting.
Develop collaborative relationships with business partners and matrixed vendors to execute day-to-day operations.
Inform management of California Department of Health Care Services trends to support short- and long-range plans.
Oversee system conversions where applicable and coordinate with stakeholders on operational changes.
Identify and resolve technical, operational, and organizational problems inside and outside the health plan.
Lead teams to resolve cross-functional business problems and foster teamwork and inclusion.
Drive high-quality execution and operational excellence by providing clear direction and expectations.
Review and approve workflows and documentation for all claims-related functions and projects, ensuring completeness and accuracy.
Monitor delegated entities for claims compliance from regulatory and contractual perspectives.
Prepare materials for internal and external regulatory audits and legal requests.
Address escalating claims issues from providers and members to facilitate timely and courteous resolution.
Manage, develop, and lead staff; build an effective team with appropriate staffing and development.
Translate strategic goals into operating and resource plans.
Coordinate and supervise operational analyses and implementation support on major workflow and claims system modifications.
Act as a consultant to senior management on reimbursement methodologies, regulatory requirements, and claims processing protocols.
Collaborate with recovery vendors to identify funds paid in error and report recoveries.
Manage and develop the annual budget for the claims department.
Maintain external contact with regulatory agencies, providers, delegated entities, community-based organizations, and other health plans on issues related to grievances and appeals.
Minimum Qualifications
Education & Experience:
High School graduate or GED; 8+ years of professional-level experience in a claims processing department as a manager, preferably in a Medi-Cal/Medicaid managed care plan.
Excellent understanding of claims regulatory requirements including AB1455, AB97, COB, and clinical editing (NCCI).
Knowledge, Skills & Abilities
Preferred Qualifications:
Bachelor’s Degree (four-year college or technical school).
Prior experience with Meditrac claims processing system, Optum CES, Easy Group, and MHK.
Analytical ability, judgment, and problem solving with the ability to present complex information clearly.
Ability to interpret and revise policies and procedures; develop operational goals and service levels.
Maintain knowledge of the health plan’s benefit structure and manage projects to optimize resources.
Develop cooperative working relationships, select and develop staff, and operate in a fast-paced, performance-oriented environment.
Prepare clear written materials and maintain confidentiality of sensitive information.
Computer Skills Advanced computer skills in MS Office products, including Access.
Certifications & Licenses A valid and current Driver's License, Auto Insurance, and professional licensure(s).
Competencies
Management, Business Acumen, Decision Making, Goal Orientation, Interpersonal and Diversity Awareness
Time Management, Consensus Building, Relationship Building, Presentation Skills
Delegation, Leadership, Ethics, Judgment, Communication (Oral & Written), Problem Solving
Physical Demands O (Occasionally) up to 33% of the time; F (Frequently) 33%-66%; C (Constantly) >66%. Stand, Walk, Sit, Manipulate, Reach, Grasp, Lift 10-20 lbs, Carry 10-20 lbs as indicated.
Work Environment Office work environment.
Compensation The estimated pay range for the position is $142,000.00 - $213,000.00 for California. Pay range varies by location, experience, and internal pay bands.
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