Mgr, Exec DOBI Compl & Appls

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

3d•$109,600 - $149,625

About The Position

The Manager oversees a team that researches and responds to escalated complaints received from regulatory offices—including the Department of Banking and Insurance, Offices of the Attorney General, and legislative offices—as well as complaints received by Horizon executives and the Office of Public Affairs. The Manager ensures that mandated and internal timeliness, quality, and production goals are achieved. The role directs staff handling sensitive, escalated complaint issues and supports member satisfaction within required resolution timeframes. It develops and monitors staff goals, provides coaching, maintains complaint and appeal training and administrative policies, and works across the enterprise to improve processes and ensure compliance. The Manager also develops business partnerships, manages service-level agreements, and represents the department and enterprise to regulatory agencies. Some travel may be required. Horizon employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED required.
At least five years of managerial experience required.
Experience managing in a fast-paced, high-volume, transaction-driven environment.
Proficiency in service operations, including management of inbound customer-service call centers, claims, membership, and billing processes.
Knowledge of industry trends, legislation, and project management execution.
Knowledge of state and federal mandates and regulations, and Health Care Reform.
Knowledge of NCQA requirements and policies.
Knowledge of DOL regulations as they relate to member appeals.
Strong leadership, decision-making, strategic problem-solving, negotiation, analytical, verbal and written communication, and interpersonal skills.
Ability to understand and interpret consumer and group health plan contracts.
Results-driven, improvement-focused, action-oriented approach; ability to handle multiple responsibilities proactively and seek better ways of working.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

Bachelor’s degree preferred.
Successful track record managing inventory and other service-operations metrics and reports, with process-improvement experience preferred.
Knowledge of healthcare or insurance policy and/or operations preferred.

Responsibilities

Direct staff handling sensitive and escalated complaints to support member satisfaction and meet mandated resolution timeframes.
Develop and monitor staff goals and provide ongoing feedback and coaching, including outside the department where appropriate.
Develop and update enterprise-wide training materials related to complaint and appeal handling.
Prepare and monitor the Enterprise Corrective Action Plan for complaint and appeal timeliness.
Identify opportunities and best practices, and implement process improvements such as root-cause analysis and technological assessments to optimize performance and administrative cost.
Ensure timely adherence to compliance, training, and reporting requirements set by internal and external regulatory or accreditation agencies and policies.
Develop, administer, and monitor Service Level Agreements with business partners to ensure timely and accurate responses to escalated complaints.
Review and maintain enterprise administrative policies and charters governing inquiries, complaints, and appeals.
Develop and maintain business partnerships and represent the department and enterprise to regulatory agencies.
Perform other related tasks as assigned or required.