· Job Description:
The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs
· Participates, coordinates and leads in the identification, documentation, analysis and validation of advanced business processes, systems, and solution requirements.
· Leads the research, evaluation and design components of complex solutions to problems.
· Provides expertise and guidance to support requirements of large cross- functional initiatives and projects, while contributing to the development and techniques used to meet the requirements of the business unit.
· Develop strategies and provide leadership toward the analysis, information validation, and decision- making process in a team environment, while ensuring cross-functional requirements/needs are met.
· Provides leadership and facilitates process improvements that cross functional business units and ensure customer satisfaction.
· Managelead multiple assignments with no supervision.
Education and Experience Required:
· Bachelor's degree in healthcare or related field.
· Must have current certification and licensing in area of expertise. May hold advanced certification in work field.
· Typically minimum of 12+ years of relevant experience with Bachelor's degree.
· Typically, 12+ years of working experience.
· Must possess current certification, including necessary licenses, for the field of specialty. (as required)
Knowledge and Skills:
· Experience with expert knowledge of commercial and government insurance programs.
· Extensive level of understanding and application of healthcare related technologies.
· Experience leading large projects, managing the implementation of a new/ expanded business process, interpreting research, and providing complex problem resolution.
· Demonstrated leadership ability.
· Ability to lead andmanage a cross-functional team in the planning, development and resolution of complex projects/issues.
· Excellent written, verbal, and presentation skills.
· Demonstrated ability to develop and present a wide variety of complex materials and communications that will be used to effectively reach both internal and external customers, and build trusting relationships through collaborative work activities.
· Strong proposal writing and editing skills.
· Proactively and accurately assesses the time and resources needed to complete an assignment.
· Experienced in teaching others to research and resolve customer inquiries by identifying trends and utilizing available resources.
· Self-motivated with excellent time management and organizational skills.
· Ability to work and communicate with high level executives and government officials.
· Must possess current certification, including necessary licenses, for the field of specialty. (as required by the position)