Cigna Healthcare · 6 hours ago

Individual & Family Plans (IFP) Claims Strategy and Payment Integrity Senior Manager - Remote - Cigna Healthcare

United States

Full-time

Remote

Senior Level, Lead/Staff

$112K/yr - $186K/yr

10+ years exp

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Responsibilities

Liaison for Claim Operations and lead for claim administration.

Collaborate with financial risk and analytics team and other partners to establish and/or monitor reports and analytics to identify and remediate spend leakage

Drive delivery of solutions to prevent claim overpayments, unnecessary claim spend, and ensure timeliness and accuracy of claim administration.

Evolve SLAs and oversees business partner claims processing and auditing to ensure SLAs are met, inclusive of accountability for Claims Monthly Operating Review, Claim Accuracy workgroup, and Claim Payment Integrity workgroup.

Represent IFP in claim payment policy, process, and technology solutions to ensure IFP’s unique needs are met

Oversee the development and implementation of internal/external controls to ensure administrative cost-effectiveness, accurate and correct coverage determinations

Review and interpret operational metrics (i.e. % pend, denied, paid, case mix, catastrophic claims expense, etc.) to assess need for procedural revisions and enhancements; participate in the design and implementation of specific systems to enhance claim adjudication processes.

Have an excellent grasp of the claims system and overall workflow

Keep up to date with carrier/coding/billing rule changes to ensure compliance with state regulations and/or provider contracts. Support operations application of rules to apply for pre and post pay claim edits and recovery identification and pursuit.

Support development and implementation of long term claim operations strategic roadmap inclusive of claim platform, claim policies and processes, and claim operations model.

Lead, coach, develop, and manage a small team of individuals to support employee development and strengthen IFP’s claim performance.

Qualification

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Claim OperationsPayment IntegrityHealth Claim OperationsClaims AuditingClaims EditingTeam DevelopmentProcess DesignACA Claim OperationsMetrics ManagementOperational Metrics ReviewProject ManagementWasteAbuseThird Party LiabilityStakeholder Engagement

Required

Minimum 10 years’ health claim operations experience, including a minimum of 5 years’ experience in ACA Claim Operations and/or Payment Integrity functions, such as claims editing, claim coding, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and third party liability

7+ years management and leadership experience

Ability to communicate clearly and concisely with stakeholders in all facets of the business, including operations, finance, and legal. Must also have the ability to communicate at all levels, from customer service agents to senior leadership team.

Strong project management skills and ability to meet aggressive deadlines, bias towards action

Ability to proactively partner cross-functionally to solve complex business problems

Strong prioritization skills, especially in a fast-moving environment

Proficiency with designing process and workflows that streamline operations

Ability to identify key metrics and manage to those metrics

Out-of-the-box thinker who will find creative ways to solve problems with multiple stakeholders

Experience working in a start-up environment and the ability to prioritize in a fast-moving environment