Vice President Processing Services (REMOTE)

AmeriHealth Caritas Health Plan

Job Description

Responsibilities:

Reporting to the Senior Vice President, Enterprise Operations, the Vice President, Processing Services is responsible for the enterprise direction and organization of all transactional processing activities including claims processing and payment, member enrollment, Third Party Liability and Coordination of Benefits activity and supporting provider credentialing and data maintenance activities. This role is responsible for ensuring all areas meet their established SLAs, stringent quality standards and regulatory requirements. The scope of this role is to support the enterprise's portfolio of product lines, health plans, TPAs, and other potential projects and product types. The Vice President, Processing Services will collaborate with the Operations Support and Optimization and Efficiency verticals to obtain robotic processing automation, workforce management, training, quality assurance and system configuration support.

  • Direction and accountability for the front-end claims processing, claims projects, and research and analysis; accountable for root cause analyses of claims issues and implementation of enterprise-wide solutions.
  • Accountable for meeting established regulatory, contractual, and operational standards and goals as it relates to the performance and services of the enterprise claims function.This includes achievement of time to pay requirements and all internal and external quality levels for both claims processing and claims payment.
  • Interfaces with external stakeholders (e.g. high-profile providers) and internal and external clients (e.g. TPA clients, health plans, product lines, etc.) to assist with and resolve claims issues.
  • Engages external partners and provides 10 - 15 yrs. experience in Health Care; 10 -12 yrs. claims center management experience, with experience managing a large claims staff preferably in multiple locations. Additional experience with provider data processes a plusoversight of the intake of claims through electronic and paper clearinghouses to ensure completeness of claim submissions and diagnose any potential issues.
  • Accountable for the accurate and timely processing of enrollment, Third Party Liability and Coordination of Benefits information.
  • Responsible for supporting corporate provider credentialing and data maintenance records.
  • Collaborates with other core functions within Enterprise Operations and the company to drive increased automation of and optimization of all processing functions.
  • Partners with Workforce Management, Quality Assurance and Training to ensure appropriate capacity and staffing levels for ongoing and future operations.
  • Primary corporate contact and business liaison with external vendors that support processing services including claims, enrollment processes, e.g., paper processing vendor.
  • Oversees large, multi-site processing team and support vendors.

Education/ Experience:
  • Bachelor's Degree.
  • Experience working in a large highly matrixed organization, with proven ability to develop internal enterprise relations, and external relationships with the medical community.
  • Ability to lead teams and direct workflow across several departments and functions.
  • Ability to travel approximately 15-20%of the time.
  • Previous experience evaluating and developing operational strategy and performance in a metrics-based environment.
  • Prior staff management experience required with demonstrated success in managing and motivating a large staff, including virtual staff, across multiple locations.
  • Deep understanding of claim processes and edits, member enrollment and provider data; experience with FACETS and provider enrollment/maintenance systems a plus.
  • 10 to 15 years experience in Health Care.
  • 10 to 12 years claims center management experience, with experience managing a large claims staff preferably in multiple locations.
  • Additional experience with provider data processes a plus.

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