Job DescriptionResponsible for oversight and leadership of multiple functions that may include general business operations, member and provider customer service, benefit configuration, health plan enrollee services, local claims resolution and interface with corporate shared services and claims operations. Includes development and management of operational metrics for inventory, productivity and quality; policy and procedure development and execution; and direction of cross-functional teams. Accountable for management of departmental budget with focus on expense reduction and systems efficiencies and process improvements.
- Directs day to day operations including monitoring performance and service levels, and ensuring the compliance with policies and procedures.
- Develops and manages quality of work and execution of standards related to customer service, enrollee services and local claims resolution.
- Works collaboratively with corporate shared services to ensure business requirements and performance guarantees are met.
- Responsible for monitoring productivity and quality of work for all operations staff. This includes working in a highly matrixed organization to accomplish and manage all performance needs, including strong collaboration with claims, IT, telecom, after-hours, compliance and other departments as necessary to effectively manage day to day operational needs.
- Ensures management resulting in timely execution of provider credentialing, and organization contracts, and the flow of accurate provider data and reimbursement schedules in provider databases.
- Employs key metrics, reporting and active management approach to ensure productivity and quality.
- Provides oversight of new program implementations for successful program execution.
- Collaborates with necessary departments to plan and develop specialized member materials (handbooks, manuals, newsletters, etc.). Provides input and facilitates necessary approvals and reviews, and works closely with marketing and communications to ensure that the design, lay-out, printing, production and distribution of materials are within corporate standards.
- Develops and implements strategies to simplify processes and decrease administrative costs. Establishes standards, policies, procedures, and workflows for data entry, analysis, accuracy, reporting, database security, and data dictionary.
- Directs cross-functional projects in conjunction with various departments to develop and implement complex data collection, analysis, data quality, and reporting and data applications on a variety of information systems platforms.
- Depending on SBU supported, may direct database and information systems functions assuring quality of information and efficiency of technology.
- Responsible for department budget, ensuring necessary resources are available and efficient, cost-saving use of those resources.
- Performs other duties as assigned by management.
General Job Information
Job FamilyOperations Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date11/14/2019
Date Requisition Created11/14/2019
Work ExperienceHealthcare, Management/Leadership, Project/Program Management
EducationBachelors (Required), Masters
License and Certifications - Required
License and Certifications - PreferredPMP - Project Management Professional - Enterprise
Other Job Requirements
- Experience requirements vary based on SBU supported.
- Minimum of 8 years healthcare or managed care experience with 5 years management experience in managed care environment with profit and loss experience.
- If supporting MRx, a minimum of 8 years of government pharmacy program or pharmacy benefit management (PBM) experience plus 5 years management experience with profit and loss experience required.
- Strong operational knowledge of health plan operations, claims management and resolution, and customer service and call center experience.Healthcare or Managed Care industry knowledge and demonstrated successful management of complex, interdependent functions and/or Pharmacy Benefit knowledge of customer service, member management, data systems, database management, provider networks, claims payment, clinical services.
- Proven ability to plan, organize, schedule, direct, control, and monitor large-scale, multi-functional project activities.
- Proven experience interacting with executive management and providing concise project reporting.
- Ability to perform basic financial and quantitative analysis.
- Knowledge of information systems and e-health technologies.
- Working knowledge of MS Office Suite.
- Thorough knowledge and understanding of complex management principles, practices, methods and techniques.
- Demonstrated knowledge of and experience in managing or directing the management of operational support areas and key functions as indicated above.
- Knowledge and understanding of clinical and operations service delivery in a government health care environment, preferably pharmacy benefit management.
- Excellent verbal, written and presentation skills.
- Experience in working collaboratively and effectively with senior management and staff at all levels of an organization.
- Call Center experience is required, as is a strong knowledge of claims processing and management, familiar with health plan and State and federal requirements.
- Ability to motivate, manage and mentor teams; strong organizational skills and the ability to plan ahead, document and develop operational plan and effectively execute on them.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.