Job Description :
This job directs all aspects of the day-to-day operations of the health service insurance operations area, including member services, provider services, plan (group) services, grievances/appeals, executive inquiries/complaints for the commercial and government-sponsored business segments and where applicable, for the health plan customers of HMHS who purchase BPS services from Highmark. Manages cross-divisional interaction with other departments within HPO and with Marketing, Sales, Product, Cliicnal Services and HMHS, and where applicable with AHN, UCD and HVHC. Directs and strongly promotes the operational platform and lower-cost staffing model. Accountable for defining new and innovative service-oriented capabilities and related strategies and responsible for providing Senior Management engagement with HMHS for technical delivery of these capabilities, their operational performance and market-facing adoption. Accountable for day-to-day operating budget related to direct report areas. Drives the overall cost, strategic planning, quality and workforce effectiveness of the division employed and outsourced (on- and off-shore) service delivery resources and lead opportunities to consistently and passionately improve customer-impacting performance. Be a leader in driving management’s commitment to an environment of trust, collaboration, mutual respect and professional growth for employees while delivering on the Highmark Experience of the Future.
Communicate effectively across all levels of employees.
Implement and execute the organization’s mission, vision, and values, and maintain high employee engagement. Provide technical/professional guidance and knowledge to others within the Services Department as well as HPO organization.
Formulate and execute short and long-term operations strategy and vision for the Services department.
Define new and innovative service-oriented capabilities and related strategies and responsible for providing senior management engagement with HMHS for technical delivery of these capabilities, their operational performance and market-facing adoption.
Enhance and/or develop, implement, and enforce policies and procedures of the organization that will improve the overall operation and effectiveness of the department/organization.
Plan, develop, organize, implement, direct, and evaluate the Services Department function and performance.
Direct the daily production activities of staff member to deliver accurate, timely and efficient service to customers.
Develop gold standards for use across all sites providing servicing to members, customers and providers.
Serve as the senior manager of the operational platform and lower-cost staffing model.
Develop credibility for the Services Department by providing timely and accurate analyses of budgets, project proposals, and business trends in the Services area to assist senior leadership in performing their responsibilities.
Establish and oversee the activities of division to ensure that strategic initiatives and other projects within department are managed the same way and work toward the same goals and objectives.
Identify and address issues and opportunities with the core insurance processing and operations across and within unique business segments for commercial and government business and where applicable for HMHS's Plan customers.
Evaluate the Services Department plan for continual improvement of the efficiency and effectiveness of the group and improvements in Net Promoter Score (NPS) where applicable.
Provide individuals with professional growth opportunities.
Provide significant input and direction into the development of future operational capabilities.
Maintain awareness of both the external and internal competitive landscape, opportunities for expansion, customers, markets, and new industry developments.
Direct the global oversight of the creating and maintenance of documented processes, controls and testing for all functions and operations.
Builds partnerships between health plan and AHN leadership in the interest of advancing the advantages and value of the IDFS business model. Also serves as a key leader in the emerging model of payer/provider integration.
Ensures the delivery of high-quality, integrated administrative patient care and the effective use of resources by building strong, performance-based relationships with provider networking.
Maintains a fiscally sound, market-leading operating environment that promotes competitive delivery models, generates member value and provides outstanding care to a growing Highmark membership.
Provide accountable leadership and oversight to operational leadership in the development and implementation of service excellence, commonality and coordination across the payer /provider integrated system.
Other duties as assigned or requested.
10 years' management experience
7 years' experience presenting and communicating with large audiences
7 years' experience valuating technology for implementation
10 years' experience utilizing insurance principles and industry practices
7 years' call center experience
7 years' extensive insurance product knowledge
5 years' experience in workforce development
LICENSES AND CERTIFICATIONS
Excellent leadership and team building skills
Background in claims and customer service
Operational, technical process re-engineering and strategic development skills
Experience in major process improvement and innovation
Excellent written and verbal communication skills
Strong knowledge of service levels and service requirements
Solid negotiation and influencing skills
Effective presentation and consultative selling skills with external parties (e.g., employers, HMHS health plan customers)
Travel regularly from the office to various work sites or from site-to-site
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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