Director, Medicare Advantage Benefits and Contract Configuration at Bright Health
- Lead the develop of Bright’s Medicare Advantage (MAPD) Claims and Configuration core competency both in terms of internal execution and necessary oversight and collaboration with applicable vendors.
- Develop and maintain business policies consistent with regulatory requirements.
- Create or when necessary, collaborate with internal and external resources to create process flows, procedures, and materials (including member communications) to support claim administration and configuration.
- Develop the appropriate requirements for performance monitoring and reporting at market corporate level, both for internal and CMS needs. Monitoring includes oversight of service level contractual requirements, end to end key performance indicators impacting timely, accurate and cost-effective claims payment, CMS performance metrics and defect related statistics.
- Participate in CMS and other audits. Representing the BHP Claims and Configuration functions. Ensure timely submission of requested documents and data.
- Collaborate with vendors and internal BHP resources to ensure proper system setup and configuration. Manage the configuration and customization of technology to meet business requirements.
- Oversee the performance of these functions as performed by internal and delegated teams.
- Seek ways to achieve continued process improvement to the member and provider experience focusing on quality, timeliness and administrative cost effectiveness. Collaborate with others to create positive points of differentiation pertaining to claims administration.
- Work effectively on occasional or seasonal projects, either as lead or in collaboration with others that support claims administration or wider BHP objectives.
- Work with internal resources and vendors to create thorough, cost justified system enhancements that enhance the effectiveness of claims administration.
- Implement effective quality control and audit programs along with necessary reporting that verifies transaction accuracy and identifies error trends, defects and process improvement opportunities.
- Create necessary daily/weekly/monthly operational reporting in manner that provides the wider organization key day and insight as to the state of claim operations.
- Other duties and responsibilities as assigned.
- This position has supervisory responsibility
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s degree preferred; Ten (10) or more years of related experience required in lieu of a degree
- Eight (8) or more years of experience in health insurance operations and Medicare Advantage products.
- Five (5) or more years of experience managing a team
- QNXT Claims and Configuration experience and knowledge of Cognizant products highly preferred
- Detail oriented
- Thrive in fast-paced environments
- Excel at creating structure and bringing operational rigor to teams
- Passion for creating an effective team environment and resolving conflicts
- Self-directed and prioritize well
- Excited to take ownership at early stage of company