The Role
The role involves managing a claims team, handling operational analysis, dispute resolution, and collaborating with stakeholders to enhance claims processing efficiency.
Summary Generated by Built In
Job Summary & ResponsibilitiesPreferred Qualifications
- Manage and lead a claims team by providing training, mentorship, and best practice solutions.
- Manage daily operations of the claims team, including inventory analysis, tracking and resolution of claims
- Serve as the escalation point for complex or disputed claims and drive resolution within defined SLA.
- Monitor and analyze key performance indicators (KPIs) and take corrective actions to improve efficiency, accuracy, and customer satisfaction
- Collaborate with key stakeholders to include underwriting, LOB, legal, servicing teams to ensure a consistent and integrated approach to accurate and timely claims processing.
- Maintain documentation, audit trails, and reporting in line with internal controls and external compliance requirements.
- Contribute to the development and implementation of new policies, procedures, and systems to improve claims operations.
#LI-Hybrid
- Bachelor's degree and five years of related work experience; or equivalent combination of education and related work experience.
- Three years of experience in management, preferably within health insurance; or equivalent combination of leadership experience or experience leading teams.
- In-depth knowledge of managed care, PPO, HMO, Medicaid, Medicare Advantage, and commercial group health plans
- Strong working knowledge of claims adjudication systems (e.g., Facets, QNXT, Epic Tapestry, HealthEdge)
- Effective written and verbal communication skills
- Intermediate working knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.
Top Skills
Epic Tapestry
Facets
Healthedge
MS Office
Qnxt
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The Company
What We Do
The Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, is a reliable name in Hawaii health care. Established in 1938, we are the largest and most experienced provider of health care coverage in the state. Over half of Hawaii’s population have chosen HMSA for their health care coverage.
We are dedicated to providing quality, affordable health plans; employee benefit services; and worksite wellness programs. HMSA also offers a variety of programs, services and support to help improve the health and well-being of our members and community.
