Manager, Claims Policy

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary :

Responsible for the general operational oversight of Claims, Service Requests, and Medical Records teams to ensure enterprise and divisional performance goals are achieved.

• Evaluate and modify business models (i.e., inventory data, staffing levels, hiring plan analysis and results, budget allocation and resources) through strategic planning.
• Identify opportunities and implement process improvements (i.e., root cause analysis, technological assessments, etc.) to optimize performance and administrative cost.
• Create an environment that fosters a positive experience for employees, internal and external customers.
• Responsible for timely adherence with compliance, training and reporting requirements as determined by internal and external regulatory / accreditation agencies and policies.
• Ensure staff comprehends and complies with; best practices, professional standards, internal policies and procedures.
• Develop, administer and monitor Service Level Agreements (SLAs) with appropriate business partners.
• Initiate, lead or participate in both internal / external workgroups / committees, maintain internal / external business partnerships and represent department / enterprise where appropriate.
• Accountable for maintaining effective internal controls over the processes and transactions under areas of responsibility including the completeness and accuracy of financial information and transactions, compliance with applicable laws and regulations, and the effectiveness and efficiency of operations.
• Review newly developed and integrated medical policies to make clinical determinations on operational effectiveness and medical cases.
• Assist Medical Directors in identifying opportunities for development of or revisions to Horizon Medical Policy based on case review determination analysis and trend.
• Responsible for identifying areas and pursuing solutions where medical policy is not being applied correctly in claim payment outcome.
• Partner with utilization review teams in the review, coordination and resolution of issues.
• Participate in office manager seminars and reimbursement committee meetings.
• Evaluate the Blue Card medical record process and monitor Blue Card performance goals based on IPP scorecard requirements.
• Partner with and provide feedback to vendor delegates based on operational assessments.
• Direct staff to ensure overall client satisfaction and appropriate level of service delivery. Develop and monitor goals for staff and provide ongoing feedback and coaching.

Manage staff, including individual contributors and supervisors including; succession planning, talent acquisition, retention, development, annual performance evaluations, skills assessment, training and matters of compensation.

Perform other related tasks as assigned or required by operational need.

Core Leadership Competencies :

• Personal and professional attributes which are critical to successful performance of Horizon-BCBSNJ employees.
• Customer Focus
• Driving for Results
• Adaptability
• Communicating with Impact
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

Qualifications

Education / Experience :

• Bachelor's Degree or relevant experience in lieu of degree
• Three (3) years of supervisory experience.
• Five (5) years related experience.

Additional licensing, certifications, registrations :

Knowledge :

• Requires working knowledge of medical policy processes, procedures and execution.
• Healthcare and health insurance industry
• Microsoft Office (Excel, PowerPoint, and Word)
• Requires knowledge of health care delivery systems.
• Requires in depth knowledge of CPT, ICD-9 and 10, and HCPC coding structure.
• Requires working knowledge of medical policy processing and files.

Skills and Abilities :

• Requires strategic planning and project management skills.
• Requires strong verbal and written communication skills.
• Requires the ability to adapt to change and meet deliverables in a fast paced, dynamic environment.
• Requires the ability to research and resolve problems through cross divisional interactions.
• Requires the ability to organize and prioritize work assignments.
• Requires the ability to work independently and coordinate projects.
• Requires analytical and problem solving skills

Travel % (If Applicable) :

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law

Salary Range : $106,400 - $145,215

$106,400 - $145,215

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to : education, experience, licensure, certifications, geographic location, and internal equity.

This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Horizon also provides a comprehensive compensation and benefits package which includes :

Comprehensive health benefits (Medical / Dental / Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.