Cost of Benefits Solutions Manager

Role Description

The Cost of Benefits (COB) Solutions Manager works directly with internal and external stakeholders including but not limited to Operations, Vendors, Provider Network and IS in the identification of COB overpayment and operational process improvement opportunities. This manager will lead the development and utilization of any internal/external tools to assist in COB processing and recovery. In addition, this role assists Fraud, Waste, and Abuse [FWA] with predictive analytics and trend reporting. A successful candidate will have very strong analytical skills, be comfortable with SQL, have strong communication skills and have a passion for using data to drive business decisions and cost savings.

This is a 100% Remote position but you must live in EST or CST time zones.

Responsibilities

• Technical:
  • Will be the point of contact for any global IS issues impacting COB processes, including but not limited to internal/external file transfers, Facets updates, TPL data load logic, PMO related projects.
  • Responsible for vendor data file layout version control and definitions.
  • Will coordinate any technical calls with IS to support our vendor partners to ensure their success.
  • Point of contact for solutioning impacts of new business requirements coming from existing plans, including coordinating with departmental peers.
  • Develop process improvement initiatives to present to senior leadership.
  • Represent the department for any ISCA audits or report development.
  • Will lead the development and utilization of any internal/external tools to assist in COB processing and recovery.
• Reporting:
  • Act as the SME regarding TPL Dashboard reporting requirements.
  • Develop ad hoc analysis at senior leadership request (ROI, CBA etc.).
  • Responsible for any outside ad hoc reporting development or validation.
  • Point of contact for any TPL data reconciliations (TPL data source system vs. sub-cons).
• Other:
  • Maintain accurate SOP for any recurring internal reporting (inventory reporting etc.).
  • Point of contact for TPL inventory data feeds to WFM.
  • Recruit, develop, and motivate staff. Continuously improve skill knowledge and staff capabilities.

Qualifications

• Bachelor’s Degree and five to ten (5 – 10) years’ experience.
• Knowledge of claims processing systems; Facets claims system a plus.
• SQL query experience.
• Knowledge of COB processing rules for Medicaid and Medicare.
• Familiarity with SDLC as it relates to developing new systems.
• Knowledge of subrogation case rules and regulation for Medicaid, Medicare, and Exchange products.
• Ability to develop reports or take existing reports with KPIs and create actionable plans for overall end to end improvements for TPL and Subrogation processes.

Benefits

• Flexible work solutions including remote options, hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents on Day 1.
• 401(k).
• Tuition reimbursement and more.