Mgr, Exec DOBI Compl & Appls

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

3d•$109,600 - $149,625•Onsite

About The Position

Responsible for the oversight of a team dedicated to researching and responding to escalated complaints received from regulatory offices, e.g. Department of Banking and Insurance, Offices of the Attorney General, Legislative offices as well as those that are received by Horizon executives and the office of Public Affairs. The Manager is responsible for ensuring mandated and internal goals for timeliness, quality, and production are achieved.

Requirements

HS Diploma or GED required.
Minimum of five (5) years of managerial experience required.
Experience managing in a fast-paced, high volume, transaction-driven environment necessary.
Successful track record managing inventory as well as other service operations metrics and reports, with process improvement experience preferred.
Proficient in service operations; managing inbound customer service call centers claims, call center, membership and billing processes.
Knowledge of industry trends, legislation, and execution of project management.
Knowledge of State and Federal Mandates, regulations, Health Care Reform.
Knowledge of NCQA requirements and policies.
Knowledge of healthcare or insurance policy and/or operations preferred.
Requires knowledge of DOL regulations as they relate to member appeals.
Strong leadership, decision-making, strategic problem solving, negotiations, analytical, excellent verbal & written, and interpersonal skills.
Strong and effective communication skills, both verbal and written.
Strong analytical skills; uses to validate plans and approaches.
Ability to understand and interpret consumer and group health plan contracts.
A commitment to excellence and to making a difference; results driven, improvement focused, and action oriented self-starter who can handle various responsibilities simultaneously and proactively and continually look for a better way of doing things.

Nice To Haves

Bachelors Degree preferred.
process improvement experience preferred.
Knowledge of healthcare or insurance policy and/or operations preferred.

Responsibilities

Direct staff to ensure overall member satisfaction while handling sensitive and escalated complaint issues within mandated resolution timeframes.
Develop and monitor goals for staff and provide ongoing feedback and coaching both internally and outside of the department, where appropriate.
Develop/Update enterprise-wide training material relative to Complaint/Appeal handling.
Prepare and Monitor Enterprise Corrective Action Plan for Complaint/Appeal timeliness.
Identify opportunities and best practices and implement process improvements (i.e., root cause analysis, technological assessments, etc.) to optimize performance and administrative cost. These improvements can be internal or may involve other departments within the organization.
Responsible for timely adherence with compliance, training, and reporting requirements as determined by internal and external regulatory/accreditation agencies and policies.
Develop, administer, and monitor Service Level Agreements (SLAs) with appropriate business partners to ensure timely and accurate responses to escalated complaints.
Review and maintain Enterprise Administrative policies and Charters that govern Inquiries, Complaints, and Appeals.
Develop and/or maintain business partnerships and represent the department and the enterprise to Regulatory agencies.
Perform other related tasks as assigned or required.