DescriptionThe Manager, Claims Quality Audit audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. The Manager, Claims Quality Audit works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.
Humana Government Business is responsible for administering the military healthcare for the DOD under the TRIACRE contract. The Manager Claims Oversight will provide management and direction for a team of associates within the Claims Oversight Department. Will be responsible for training and development of assigned associates, delegation of responsibilities and interactions with business partners in order for the team to meet or exceed the metrics of the contract for the assigned areas of the Claims Oversight Department.
Our Department of Defense Contract requires U.S. citizenship for this position.
-Perform management and leadership activities such as routine HR functions, recruiting, onboarding, training, problem resolution, addressing escalations and customer interface.
- Assist team members in recognizing opportunities and defining requirements to improve claims adjudication processes and outcomes. Facilitate analysis and identification of key claims processes that need to be improved – either due a business initiative, system issue, or government directed change.
- Research, develop and implement change to improve business processes. Ensure team members use TRICARE policy and industry guidelines to create, improve, and implement new processes to meet objectives. Evaluate the effects of change by quantitatively and qualitatively measuring them against internal and external benchmarks.
- Establish the criteria for the efficient management and measurement of area responsibilities. Encourage team members to develop analysis and presentation skills which draw insights from data and tell the story of what the information means in order to inform decisions and actions.
• Writing and maintaining department process documentation, process flows, and policies and procedures.
• Cross-communication with Humana Military Functional Areas, IT, and subcontractors in regards to issues, progress, and next steps.
• Oversight of department metrics and key operating indicators – utilize to identify and implement continuous process improvement.
• Proactively identifies improvement opportunities as well as providing subject matter expertise and analysis to issues, changes, and improvements based on industry and competitive trends and analysis of current processes and barriers.
• Ensures documentation of business needs for innovative business processes that support Claims Oversight solutions, create sustainable competitive advantage and administrative efficiencies.
• Utilizes project management principles to oversee project and program implementation efforts to ensure expected results are achieved.
• Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and role essentials.
• Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
Typically requires Bachelor's Degree or equivalent work experience
Prior Tricare experience
Prior Leadership experience
Five years of business analysis, project, and process management experience
Prior Claims Operations experience
Proficiency in Microsoft Access, Excel and Word
Ability to read and interpret documents such as contracts and government policy
High level of problem-solving and analytical skills
Strong consultative skills and relationship building skills - able to promote teamwork and build effective relationships while meeting objectives
Superior written and verbal communication skills and strong customer service skills
Excellent planning and organizational skills
Ability to take initiative and meet objectives
Ability manage and prioritize multiple initiatives with minimal guidance
Ability to successfully handle change in a fast paced environment
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
Working knowledge of claims processing systems and medical claims data - ability to understand claims adjudication, systems and reporting
Prior demonstrated experience with process improvement or process design and implementation roles
Requires knowledge in healthcare related business applications and technology.
Scheduled Weekly Hours40