Position : HEAD OF CLAIMS ADMINISTRATION

Department : OPERATIONS

Reports to : PRESIDENT 

SCOPE OF WORK/FUNCTION 

• As the Head of Claims and Customer Service (CS) for Discover ASO Corp. aka SIMPLeTPA, he/she is primarily responsible to assure claims are managed within the specific plan guidelines and charges for claims services are reasonable and customary.  In order to perform this role in an efficient manner, the Head of Claims and Customer services will be integral involved as the subject matter expert (SME) for the design and development of our digital claims adjudication and management platform.  To support this role, Head of Claims and CS will directly manage the company’s customer service relationship team, escalate concerns and deploy preventive measures to address possible issues of clients that may arise. As a founding team member, he/she will have the opportunity to heavily influence the overall company, market and platform development. As the scale of the operation increases, there will be an opportunity to level up the Claims and CS roles to fit the scale.

SERVICES TO MARKET 

• Claims Adjudication, Customer Service, Relationship Management, Business Management, Customer Experience

DUTIES AND RESPONSIBILITIES 

• Support the design, implementation and continuous management of the rapid claims management system – including gathering and monitoring claims costs on a treatment and/or DRG basis.  The role involves keeping up on trends and innovation in the healthcare industry that is delivering better healthcare outcomes at the best price.
• Work with insurance and healthcare partners to assure proper alignment and coordination on all claims processing where applicable
• Direct and manage team of claims adjudicators and customer services specialist to adjudicate non-standard claims; where necessary monitors daily patient’s progress chart to know patient’s needs.
• Monitor and audit claim trends for potential fraud or overutilization; explore alternate and preventative medical treatments/protocols
• Work as key team member for building out the claims management platform to deliver customer-centric solutions to ease the healthcare process and mitigate any surprises in the claims/GOP processes

• Address and act as key decision maker with customers, medical providers or other interested parties when dealing with special or challenging medical conditions and/or treatment decisions
• Continuously update and maintain databases required to support the claims adjudication system (includes both list of preferred providers as well as the industry standard “usual and customary” costs and protocols for specific conditions
• Draft and maintain appropriate risk management guidelines and policies for medical decision making, appeal processes and other related issues for both SIMPLeTPA self-insured plans as well as plans provided in coordination with other insurance companies
• Manages the workload balance, including acting as a backup as required
• Develops tools and reports for claims and customer service performance as needed

QUALIFICATIONS 

• With 8+ years of relevant experience in medical claims processing
• Demonstrated experience working with medical providers to resolve difficult claim cases
• History of innovative, creative and driven worker
• Prefer graduate of medical, nursing or related medical certification programs
• Excellent written and verbal communication skills
• Knowledgeable on digital enterprise workspace productivity tools (e.g. excel, word and ppt or equivalent); experience working with data analytic tools highly appreciated

ACKNOWLEDGEMENT AND ACCEPTANCE 

I certify that I have read and I understand the duties and responsibilities and other features and dimensions of the job, as specified and stated in this Job Description. I accept these duties and responsibilities and agree to maximize and optimize existing competencies and develop new competencies to achieve the different performance and competency standards.