Posted in Other 30+ days ago.
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Type: Full Time
Location: Watertown, Massachusetts
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)
Responsible for overseeing all department operations pertaining to data entry, maintenance and reconciliation of member data as well as the documentation and configuration of plans and benefits.
Responsible for ensuring the quality, timeliness and compliance of all organizational processes and reporting as they relate to member data and benefit configuration.
Accountable for the enrollment reconciliations for multiple lines of business and is accountable for the premium reconciliation which includes oversight of rate tables, the generation of expected premiums. This role is responsible for the timely reporting of enrollment and premium discrepancies to Government agencies and external business partners.
Participate in the development and implementation of regulatory, corporate and new business initiatives as it relates to member data and/or plan benefits and documentation. This role will initiate and leads cross departmental activities to improve the quality of member data and is responsible for bringing such projects to completion.
Serves as the key enrollment contact externally, with state agencies and has primary responsibility to ensure all required reporting functions are delivered accurately and timely. This position will independently assess business needs and solution options and present proposals for implementation of business process change to meet an evolving business model and regulatory requirements.
Leads and coordinates development, testing and implementation of key department projects and with other departments within Tufts Health Plan, internal staff and external parties.
Represent the Enrollment and Benefit Configuration team on enterprise wide projects such as the annual production of 1099-HC and 1095 forms, the MLR Reimbursement process, audits and compliance initiatives.
Leads the team in the identification, organization and execution of key initiatives, innovation and process improvements for the department
Oversees day-to-day operations to ensure that all member data is entered accurately into the member enrollment, benefit configuration and revenue applications and that incoming requests are processed within the required time frames. Manages accurate and timely processing of enrollment and premium reconciliations to meet state and federal requirements for MassHealth, QHP and the Unify lines of business.
Initiates interdepartmental projects to improve the quality of the member data and staff workflow process. Serves as the business owner and subject matter expert to bring projects to completion. Continually looks for new opportunities to achieve efficiencies.
Leads team members in performing their daily responsibilities: provides feedback and coaching via regular one-on-one meetings; and holds regular staff meetings to provide training and information. As a Manager, this role is also responsible for measuring employee productivity and coaching staff to reach optimal performance and quality; conducting formal performance appraisals; and, when necessary, appropriate disciplinary action in a timely manner and in accordance to Tufts Health Plan Human Resources policies and procedures.
Makes manager-level decisions for the department regarding issues affecting data quality, and trains and delegates accordingly. Trouble-shoots problems related to the file loading processes and other member-related functions, and works with the appropriate resources to get them resolved. Develops and monitors quality reports to identify issues proactively when possible.
Maintains a thorough understanding of the member enrollment, benefit configuration and revenue applications, data integrity and its impact on other parts of the organization. Establishes, builds, and maintains positive working relationships with other Tufts Health Plan departments, including Claims, Medical Management, Marketing, Product Management, Member Services, Pharmacy, Clinical Services, Network Contacting and IT to ensure that all data is processed efficiently and with accuracy.
The person in this position maintains professional growth and development through self-directed learning activities and involvement in professional, civic, and community organizations; encourages a high work ethic within the department by demonstrating appropriate and acceptable behavioral skills; encourages and precipitates a collaborative work environment among team members; and develops benchmarks for best practices related to all major functions.
Participates as team leader and/or team member on special projects as assigned and all other duties as assigned.
EDUCATION: Bachelor's Degree, or equivalent work experience required; Advanced degree preferred in business or related to health care industry.
* 5 to 7 years working with operational and technical aspects of managed care required; healthcare experience preferred, particularly in the areas of claims and/or enrollment processing.
* Supervisory experience required.
* Experience with analysis of operational issues and advanced problem solving skills required.
* Experience using SQL Server or Microsoft Access to create queries is a strong plus.
* Proven track records for establishing, building, and maintaining relationships.
* Demonstrated verbal, written and presentation skills.
* Ability to work collaboratively as a member of cross-functional teams.
* Ability to negotiate and resolve differences.
* Ability to motivate staff to achieve a high level of performance.
* Ability to be flexible and adapt to change as a result of industry and organizational changes.
* Ability to streamline and improve operational processes and metrics.
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS
* Fast-paced office environment and may require limited travel between Tufts HP offices and offsite vendors.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled