Description

OVERVIEW

Provide leadership and direction to Medical Payments and Bill Review Team across all four brands.  Act as a primary, independent, visionary, and proactive authority; providing in-depth analysis of medical payments areas including statistical, industrial and regulatory perspectives.  Provide operational consistency and integrity to claims and the medical payments processes. Serve as a technical expert with regard to department operations. Collaborate with Brand Leadership, Corporate Claims, and OGC/Compliance to ensure timely and accurate medical payments in compliance with statutory and regulatory requirements.  Represent AF Group in/at industry functions with regulators, vendors, and peer groups; WCRI, NCCI, etc. Maximize efficiency and savings in MBR and with Vendor Management and Pharmacy Programs. 

RESPONSIBILITIES

• Plan, direct, manage and evaluate the day-to-day operations and workflow of production, claims management and customer teams.
• Consult with Claims, Corporate Claims, Government Affairs and OGC leadership across the organization to provide necessary support and feedback to ensure most productive, efficient, compliant, and cost-effective ways to conduct business.
• Serve as lead contact and oversees the management of the Medical Bill Review software partner and any outside review vendors.
• Attends industry functions with regulators, vendors and peer groups, to represent AF Group to ensure best in class medical bill review program.
• Responsible for the development, implementation and maintenance of the Medical Bill Review Quality Assurance Program.
• Responsible for staying current on changes in workers’ compensation statutes and cases; medical fee schedules and reimbursement methodologies as well as subrogation and recovery laws and procedures.
• Conduct and/or direct advanced statistical analysis and research related to medical reimbursements, claims and claims operations.
• Oversee and manage strong, professional working relationships with state regulatory agencies, as well as vendors, by serving as a key contact.  This includes ensuring quality communication and exceptional work product.
• Collaborate with appropriate parties in root cause analysis and minimization of delays, surcharges, fines, and penalties.
• Participate in development of annual departmental budget.
• Establishes and monitors KPIs and SLAs for departmental success and compliance. 

Requirements

EXPERIENCE

• Bachelor’s degree in insurance, business or a related field required.  Certification or progress toward certification is highly preferred and encouraged.
  
  

EXPERIENCE

• Eight (8) years experience of progressive responsibility in a claims Medical Bill Review environment with demonstrated technical knowledge. 
• Minimum three (3) years of demonstrated leadership ability in a claims or medical bill review environment required. 

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED

• Working knowledge of workers' compensation statutes and fee schedules, medical reimbursement methodologies, filing procedures, settlement options, claims processes, and medical terminology. 
  Demonstrated leadership ability.    
• Ability to bridge IT requirements and departmental needs.
• Excellent analytical skills to identify improvement needs and develop solutions.
• Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information and respond to questions as appropriate.
• Strong interpersonal skills and the ability to negotiate while creating and maintaining mutually beneficial relationships with working partners.
• Ability and proficiency in the use of computers and company standard software, including advanced knowledge in Excel, and other corporate databases.
• Ability to establish workflows, manage multiple projects and meet necessary deadlines.
• Ability to comprehend the consequences of various problem situations and address them or refer them for the appropriate decision-making.  Independently resolves most problems.
• Ability to read, analyze, interpret and effectively present budgetary and/or cost information and respond to questions as appropriate.
• Ability to maintain confidentiality.
   

SUPERVISORY RESPONSIBILITIES

Directly supervises a varied number of employees in the designated department(s). Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

ADDITIONAL INFORMATION 

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. This job description does not constitute a contract for employment.