Rating/Claims System Senior Advisor

Location: This position will work a hybrid model (remote and office). The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations in Columbus, OH; Mason, OH; Indianapolis, IN; Chicago, IL; Manchester, NH; Boston, MA.

The Rating/Claims System Senior Advisor leads the activities for India based Commercial Claims Operations, Claims System Configuration, and Provider Data Management departments to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achievement of cost objectives and service level goals; provider data management and related downstream processes; collaboration with all other client departments to ensure client goals are achieved and compliance with guidelines are met.

How you will make an impact:

• Establish standards of performance, including training, policies and procedures, claims auditing and other performance measurement techniques.

• Oversee all activities related to claims processing.

• Primary oversight and responsibility for delegated claims functions performed by third party vendor, including claims processing and fulfillment.

• Oversee the coordination of procedures for administering the various benefit plans and provider contracts with all interfacing systems.

• Responsible for implementing and auditing benefit changes as related to claims processing.

• Responsible for monitoring Medicare changes as they relate to claims payment and methodologies, benefits and coding and billing.

• Develop and implement cost control measures.

• Responsible for directing the processing and payment of claims.

• Provides guidance on the most complex claims.

• Develops short/long-term objectives and continually monitors procedures to ensure these are met by staff.

• Stays abreast of state/federal regulations.

• Manages commercial claims processing team located in CGS’s India site.

• Works with business owners to identify and analyze requirements and processes with Information Technology and the vendor to ensure quality and timeliness of systems/project deliverables.

• Position requires significant and regular external contact with customers or regulatory agencies.

• Has significant budget accountability and manages special projects.

• Translates the most highly complex and varied business needs into application software functionality.

• These needs typically involve a significant expenditure or cost savings and impact a wide range of functions.

• Configures new designs/updates in the system.

• Monitors system and business functionality and performance.

• Documents and tracks product defects.

• Coordinates problem resolution with development and/or product vendors.

• May implement rates, rating formulas, product and benefit configuration/information and as directed by the appropriate business unit.

• Analyzes, develops and validates data.

• Researches, documents and completes very diverse and complex projects and work processes to ensure business continuity and consistency.

• Formulates and defines system scope and objectives based on user-defined requirements.

• Supports and maintains the systems post-implementation.

• Provides end user support, consultation, liaison communications, helpdesk triage, training, reporting, auditing, application security, and ad hoc inquiries and requests.

• Provides expertise to lower level analysts.

Minimum Requirements:

Requires an BA/BS degree in Information Technology, Computer Science or related field of study and a minimum of 8 years systems analyst or business analyst experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• 8-10 years of leadership and Managed Care experience, preferably in Medicare Advantage strongly preferred.

• Experience working closely with offshore IT support team strongly preferred.

• Experience with Medicare and corresponding regulatory requirements preferred.

• Comprehensive knowledge of the health insurance industry, including, but not limited to: claim adjudication procedures; insurance law; benefit design; plan document provisions and compliance regulation strongly preferred.

• Excellent analytical ability, written, oral and interpersonal communication skills, negotiation skills, PC skills, advanced strategic planning, organizational, managerial and leadership skills strongly preferred.