Posted in Other 30+ days ago.
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Type: Full Time
Location: Cincinnati, Ohio
BUILD YOUR FUTURE, WHILE PROTECTING THEIRS.
You will be challenged. Rewarded. And valued for your unique experience, background and perspective.
Join a team where hard work pays off and original thinking is celebrated. As you build your future at Westfield, you will quickly learn that protecting our customer s future is at the heart of what we do. We deliver on our promise to help restore lives and rebuild businesses when the unexpected happens. Building relationships has been a part of our culture since 1848.
Be a part of a team that recognizes and appreciates those who take initiative, seek opportunity and strive for innovation in a changing world.
Medicare Compliance Lead Job Summary
LOCATION: Westfield operationg territory
SALARY RANGE: $88,645.00-$101,942.00-$115,239.00
Senior member of Medicare Compliance Unit who actively monitors regulatory, legislative and judicial developments impacting Medicare compliance. Continually seeks opportunities to improve Medicare compliance, including claim system and document enhancements and process improvements. Gathers, organizes, maintains, and analyzes performance data and results to identify and report performance, trends, and opportunities. Assists in the creation and maintenance of Medicare compliance job aids, process flows, guidelines, etc.
Essential Functions (primary functions and/or reasons the job exists in order of importance)
1. Medicare Compliance Operations Actively monitors regulatory, legislative and judicial developments impacting Medicare compliance. In coordination with leader, creates strategies, solutions, processes, communications, and best practices to ensure ongoing Medicare compliance.
2. Process/Program/System Improvements As senior member of the Medicare Compliance Unit, continually seeks opportunities to improve Medicare compliance, including claim system and document enhancements and process improvements. Recommends changes in procedures in response to changes in Medicare compliance.
3. Data Analysis Gathers, organizes, maintains, and analyzes performance data and results to identify and report performance, trends, and opportunities. Creates reports and communicates results with leader. Supports design, development and implementation of the Medicare compliance data.
4. Training Collaborates with Medicare Compliance Unit to identify training needs and to create and maintain Medicare compliance job aids, process flows, guidelines, etc. Partners with Westfield University and/or Claims Strategy to design, develop, and deliver Medicare compliance training. May create and deliver other ad-hoc Medicare compliance training, as needed.
5. Collaboration/SME Acts as Medicare subject matter expert between Claims and IT, Government Relations, Corporate Legal, etc. Collaborates with internal/external business partners, seeking and/or providing assistance or input when needed to support Medicare compliance strategies.
6. Medicare Compliance Continually develops and maintains a thorough and working knowledge of Medicare Section 111 Reporting and Medicare as Secondary Payer requirements as well as ISO reporting process pertaining to Medicare.
7. Provides day-to-day, claim-specific support to claims professionals on Medicare Compliance. Identifies, analyzes and corrects reporting errors including defects/trends. Coordinates services with Medicare service vendor and claims professional. Shares in management of Medicare service vendor relationship. Coaches/mentors Medicare Compliance Unit and claims professionals on Medicare compliance.
8. Medicare Case Management - Opens cases with Medicare as needed. Completes all regulatory mandated Medicare reporting. Reviews, analyzes, and disputes Medicare conditional payments, as appropriate. Documents review results.
9. Claim File Audits Performs ad-hoc individual claim file reviews as needed to assist claims professionals with issues related to Medicare compliance. Participates in various internal/external compliance audits.
10. Communication Maintains effective and ongoing communication with claims department leaders and staff, internal and external business partners, insureds, claimants, agents, attorneys, other insurance companies, project team members, claims leadership, and vendors.
11. Customer Service Ensures customer service excellence. Provides excellent service to claims professionals, leaders, project teams, etc.
12. Medicare Secondary Recovery Portal (MSPRP) Access Coordinates filing of regulatory forms to maintain Medicare portal access, reports, etc. and utilizes the MSPRP for requesting, viewing or submitting information.
13. Leader Assistance Assists leader with business planning, processes, guidelines, and budget; is accountable for department expenditures. Also assists leader with identification of risk and mitigation strategies related to Medicare compliance-related issues.
14. Travels as needed in order to perform other essential functions.
Desired Qualifications/Experience/Certification/Education (in order of importance)
1. Technical expertise relative to Medicare Section 111 Reporting and Medicare as Secondary Payer requirements, and:
a. 7 years of experience handling bodily injury claims with litigation claim handling experience.
b. Juris Doctor Degree and 3 years of experience with Medicare Section 111 Reporting and Medicare as Secondary Payer requirements.
2. 1 or more years of experience leading, coaching, and/or developing direct or indirect (experience as an SME, team or project lead, mentor, etc.) reports.
3. Experience reading, analyzing and interpreting complex documents (e.g., laws, regulations, NGHP User Guide).
4. Experience using a claims management system e.g. Guidewire or diary management system to accurately document file activities.
5. Excellent analytical, tracking, and monitoring skills. Ability to collect and analyze data, identify trends, establish facts, and recommend solutions.
6. Excellent oral, written, and interpersonal skills, resulting in the ability to interact with all levels in the organization.
7. Ability to work in a team atmosphere as well as independently.
8. Strong attention to detail and ability to multi-task.
9. Vendor management experience.
10. Experience using Microsoft Office suite (e.g. Excel, Word, Outlook).
11. Ability to travel, including overnight business trips as needed.
12. Valid driver s license and a driving record that conforms to company standards.
13. Industry recognized designation, such as CPCU, SCLA, AIC, etc.
14. Bachelor s Degree or commensurate experience.
Physical Requirements (specific to the role)
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
* Ability to work effectively in an office environment for 40+ hours per week (including sitting, standing, and working on a computer for extended periods of time).
* Ability to communicate effectively in a collaborative work environment utilizing various technologies such as: telephone, computer, web, voice, teleconferencing, e-mail, etc.
* Ability to travel as required.
* Ability to operate an automobile within the parameters of the driving policy.
This job description describes the general nature and level of work performed in this role. It is not intended to be an exhaustive list of all duties, skills, responsibilities, knowledge, etc. These may be subject to change and additional functions may be assigned as needed by management.
We are an equal opportunity employer/minority/female/disability/protected veteran.