Manager - HAP Preferred Operations and Quality - Health Alliance Plan -Troy

The Manager of HAP Preferred Operations (HPO) & Quality is responsible for managing the activities associated with the third-party administrator (TPA)/Alliance Health and Life Claims Processing and Provider/Member Claim Appeals department of HAP, including claims adjudication repricing, and reinsurance for HMO, TPA, and Insured products. They will develop and maintain functional relationships with Alliance Health and Life Company, external TPA, and related internal departments. The HPO Manager will also plan, direct, evaluate and coordinate the activities managed within the Internal Quality Auditing department of Provider Operations related to operational accuracy of claims adjudication, data entry, and customer inquiries. They will support and administer corporate policies, procedures, and philosophies to promote quality customer service and control of expenses and indemnity objectives.

Principal Duties and Responsibilities:

• Provide overall direction and immediate supervision to the TPA/AHL Claims Processing and Provider/Member Claim Appeals through delegation of work assignments, projects, and tasks required to satisfy divisional and corporate goals, objectives, and strategies
• Provide overall direction and immediate supervision to the staff assigned to the Claims Quality Audit department through delegation of work assignments, projects, and tasks required to satisfy divisional and corporate goals, objectives, and strategies.
• Creates a comprehensive quality plan for each department within Provider Operations to support the organizational goals and KPIs for the given areas. Anticipates internal and/or external business challenges/ regulatory issues. Defines program scope related to Quality Assurance, establish approach for implementation and maintain the Quality Assurance infrastructure.
• Develop, secure approval of, and implement policies, procedures, and protocols necessary to achieve short and long-term goals and objectives for HMO, Insurance Company, and TPA claim processing. Communicate and adhere to corporate policies and procedures; interpret and administer departmental objectives and quality standards consistent with guidelines established or affirmed by Corporate Management
• Interview, evaluate and select personnel for the department. Review the evaluations of employee performance and recommend appropriate coaching, training, developing, and corrective action for assigned departmental staff
• Oversee the development implementation of internal/external controls to ensure medical and administrative cost effectiveness, and compliance with quality service standards and objectives
• Monitor indemnity results and service quality to identify improvement opportunities; oversee technology vision and application for HMO, insurance, and TPA claims administration through corporate systems
• Coordinate necessary activities with Legal, medical Affairs, Membership, Marketing, Finance, and Information systems departments as appropriate for areas of joint interest or responsibility
• Develop, maintain, and ensure compliance with departmental and corporate budget guidelines
• Produce, analyze, monitor, and distribute departmental reports which identify key quality, productivity and service measures
• Maintain knowledge of current trends and developments in the field through the periodic review of books, journals and literature; attend related seminars, training sessions, and conferences as appropriate for continued education