Responsible to oversee the claims team and process routine vision and medical claims for 9 Health Plans. Review claims dashboard to ensure claims are in compliance with Medicaid and Medicare guidelines. Work closely with the Configuration department to ensure the system is configured to process claims accurately and timely.

Manage and monitor a staff of 20 plus Claims Examiners, Senior Examiners and Senior Specialist.Report directly to Claims Vice President, managing and monitoring claims inquiries, adjustments, including those referred to external business partners to ensure processing are within prompt pay guidelines and meets or exceeds the established corporate turnaround time. Prepare daily, weekly, and monthly, production and inventory reports to ensure business objectives are maintained within State and Federal compliance mandates. Review internal and external Pend code reports to identify and resolve aged claims. Collaborate within areas of oversight including but not limited to BTS, Grievance and Appeals, Provider Network Management, information Technology, external vendors, Vendor Management and Human Resources to effectively develop and implement business solutions. Evaluate business processed and perform high level analysis to leverage opportunities for operational improvements.

Provided coaching, training, direction and ongoing development for call center employees. Reviewed individual production, work quality, performance management and initiate corrective action as appropriate. Managed and address daily escalated calls and tasks submitted by the Advocates. Prepare weekly reports on production and inventory and analyze trend. Performed root cause analysis to resolve issues. Conducted daily wrap-up meetings and monthly team meetings to keep staffed informed of all department updates and ensure understanding of all policies and procedures. Managed information and handled inquiries relative to the resolution of Medicare Secondary Payer and Recovery escalated issues.

Supervised day-to-day operations of the Union Support team. Monitored the telephone system and call center to assure that all calls are answered in a timely manner to meet established benchmarks. Perform random audits and silent monitoring to ensure staff’s adherence to timeframes and policies and procedures. Trained employees in process operations and act as a preceptor to newly hired staff.

Oversaw and trained the Assistant Representatives for all New Group business and managed their day to day activities. Promoted products in accordance with Emblem Health’s goals and objectives internally and externally. Collaborated with the Manager on new accounts to ensure accurate and timely implementations. Tracked and analyzed the problem resolution activity and look for root cause.Represent Emblem at various functions, including sales presentations, health fairs, seminars, enrollment meetings, dinners, etc. Scrubbed all new group applications, tax documents and member enrollment forms to submit to underwriting and ensure Underwriting guidelines are met.

•Design test plans for systems modification corrections and additions•Identify, track, research and resolve system problems•Support all aspects of departmental programming implementation, from PPM development to testing of the finishes product in multiple systems:mainframe, Network Access, Internet applications, EMC, OCR, Medicare crossover•Evaluate and recommend changes in modifications/additions as well as methods and procedures for system testing•Service as the liaison with the Directors and Managers in the Claims operations concerning the business requirements, planning, testing and communication of projects

Utilized call center technologies to monitor telephone inquiries and queue status. Maintained weekly and monthly productivity reports to review departmental activity as well as analyze trends in call volume and call type. Utilized work force Management tools to ensure schedule adherence of staff for daily phone coverage. Conducted regular coaching sessions with each advocate on the team to provide detailed feedback and quantitative work performance, attendance, work habits, goals, and areas for improvement. Conducted departmental meetings to keep staff informed of all Broker related updates, new products and company wide expansion.

Utilized call center technologies to monitor telephone inquiries and queue status. Maintained weekly and monthly productivity reports to review departmental activity as well as analyze trends in call volume and call type. Utilized work force Management tools to ensure schedule adherence of staff for daily phone coverage. Conducted regular coaching sessions with each advocate on the team to provide detailed feedback and quantitative work performance, attendance, work habits, goals, and areas for improvement. Conducted departmental meetings to keep staff informed of all Broker related updates, new products and company wide expansion.