CareFirst Careers

Director, TPA Operations

Resp & Qualifications

PURPOSE: 

The Director of Operations is primarily responsible for the core operational services of CareFirst Administrators/NCAS including the timely, accurate processing of all claims and customer service inquiries and for on-going training of operations associates for multiple work sites of NCAS.  This position is a key report directly to the Vice President and has primary accountability for growth and retention of customers through ensuring superior levels of service and has bottom line accountability for Net Income goals.

Additionally, provides direction and oversight for quality and coordination of training for all operations, plan building on the LuminX system and provider network management and file maintenance.  This position also provides key leadership to the organization through management of the Net Lease programs and is responsible for the maintenance and support of the LuminX system through the ASP arrangement with Ebix.  Leads IT/TPA Technology and Corporate Systems functions for the BU. 

PRINCIPAL ACCOUNTABILITIES:
Under the general supervision of the VP the incumbent’s accountabilities may include, but are not limited to, the following:

CLAIMS and SERVICE

•  Provides leadership to Claims and Customer Service staff to support superior levels of customer service and account retention that achieve targeted performance metrics.
•  Plans, organizes, staffs, directs, and controls the operations of the TPA across three geographically distributed operations, while ensuring consistency in workflows, systems functionality, and timely and accurate processing of claims and customer inquiries.
•  Monitors account satisfaction and adjusts operational workflows, systems, and training programs to meet and /or exceed account expectations.
•  Develops, implements and monitors budgets to ensure adequate staffing levels that consistently meet/exceed customer expectations and negotiated performance standards.
•  Ensures proper controls in workflows, systems, and standardized performance measures in the TPA, and ensures consistent quality of service by use of benchmarking “Best Industry Practices” to make NCAS recognized as an industry leader of Third Party Administration.
•  Provides a vision to the Operations Division staff which translates into an organizational culture centered on customer satisfaction, outstanding quality, and a commitment and passion for the customer.
•  Provides Net Lease services to designated groups.
•  Presents key strategies and initiatives to the President
•  Establishes “best of class” operations which support the retention and growth of business and which differentiates NCAS from its marketplace competitors and contributes to the Net Income in a positive way.
•  Direct the team of Account Liaisons that supports account management teams from an operational perspective by providing day-to-day, quality client services support to accounts, brokers, members, wholesalers, administrators and service vendors; facilitate the resolution of clients’ benefit administration concerns, problems, complaints and service and systems issues. 

STRATEGIC PLANNING

•  Researches, analyzes, and monitors the competition in three geographic markets including, Virginia, North Carolina, and Maryland to continuously gauge NCAS/CFA services as compared to the competition and assure that NCAS services remain above the marketplace in performance.
•  Continuously evaluates NCAS vendor relationships such as UR Vendors, Repricing Vendors, Rental Networks and System Vendors.  Cultivates relationships which support the NCAS core values of respect, integrity and teamwork and that lead to partnerships that support revenue growth and added value for customers and bottom line Net Income impacts. 
•  Translates strategic plans into tactical plans which are well organized, implemented and meet budget and performance target dates to ensure that both new business and existing business perceive NCAS as superior to the competition in the markets in which it operates.

PLAN BUILD/PROVIDER EDI

•  Responsible for the oversight of the EDI staff to assure timely and accurate plan building, testing and validation of the LuminX system for new and existing business. 
•  Responsible for the Provider EDI file exchange management processes. 
•  Directs the accurate and efficient plan builds and provider file records.  Also responsible for appeals and resolution for member issues.

IT & TPA Technology

•Assesses and evaluates the functionality, and efficiency of the LuminX system to assure on-going capability to service accounts. 
• Provides strategic direction for systems capabilities, systems strategies, and workflow implications relative to the LuminX platform.
• Leads strategic systems initiatives to maintain NCAS competitive edge in systems technologies and to support reengineering of workflows to assure financially sound systems strategies.
• Direct accountability for the management of network servers and server-based operations of the TPA, including integrity, security and infrastructure and coordination with CareFirst Corporate strategies and guidance.
• Directs the management of and strategic planning for the TPA telephony efforts to include the phone system, equipment and IVR.


QUALIFICATION REQUIREMENTS:
Required Education/Experience/Skills/Abilities:


Education/Experience

•   5-10 years of leading a large and complex customer service operation, call center, and/or claims department, preferably in the health insurance industry, with increasing levels of managerial expertise and responsibility.
•  5+ years of direct management experience leading diverse operations with expanding scope of responsibility, including increased numbers of staff.   
•  Must be thoroughly familiar with understanding and applying current market trends, services, contracts and pricing procedures, alternative funding arrangements, and various service products or offerings.  Experience with a variety of health insurance products such as PPOs, Reinsurance, Pharmacy Benefit Management, POS, Vision, Dental, COBRA, FSA and other services highly preferred.
• Incumbent must be able to work successfully and productively in a matrix management environment while still achieving goals and business results.  Must have the ability to deal effectively with customers, brokers, vendors and associates in a manner which maintains existing business, grows new business, and creates a positive business atmosphere.
• Must demonstrate resilience and effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. 
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.  
•Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Preferred:
Life & Health Sales Producer’s license preferred. 

#LI-CS1

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 6/21/2020

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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