Responsible for developing, establishing and maintaining the Federal Employee Program (FEP) business policy on Other Party Liability (OPL) contractual activities, as detailed in the BCBSA’s contract with the Office of Personnel Management (OPM), and reimbursement to federal health programs in accordance with regulation. Tasked with providing strategic leadership by serving as the single point of contact for complex policy and reimbursement positions pertaining to the FEP.Requires ongoing collaboration and coordination across departments and organizations, as well as with external federal agency partners, to ensure that the FEP strategic direction is both established and adhered to.

Responsible for supporting and maintaining relationships with AmeriHealth Caritas Family of Companies (ACFC) lines of business, and vendors supporting the Payment Integrity commitments of offsetting growth trends in Fraud, Waste and Abuse, Audit Recovery Operations, Coordination of Benefits, Subrogation, and all other prospective and retrospective operations. Responsible for overseeing the strategic development and implementation of vendor services to support the pre-payment and post payment efforts of the Payment Integrity Dept. to achieve best value, manage costs and manage risks related to payment integrity.Act as a liaison between vendors and AmeriHealth to ensure vendors are appropriately set up and supported, which includes contracting, access and security, training, SLAs, issue resolution, performance metrics, inventory management, goals, commission payments and performance management. Vendor oversight, ensuring that vendors have an accurate understanding of AmeriHealth Caritas products (Medicaid, Medicare-Medicaid Plans, Dual Eligible Special Needs Plans) compliance/policy requirements, CMS regulations, claims processes and systems. Monitor compliance with AmeriHealth policies and standards.Generate financial reporting and reconcile invoices.Respond to questions, resolving service, operational and process issues.

Responsible for the strategic development and implementation of vendors to support the pre-payment, post payment, cost avoidance and revenue recovery efforts of the Payment Integrity Dept. The Payment Integrity Department consists of Other Party Liability Dept. (OPL), Reimbursement Investigations Unit (RIU) and Special Investigation Unit (SIU). Act as a liaison between vendors and HealthNow to ensure vendors are appropriately set up and supported, which includes contracting, access and security, training, SLAs, issue resolution, performance metrics, goals, commission payments and performance management. Ensuring that vendors have an accurate understanding of our products, compliance/policy requirements, claims processes and systems. Monitor compliance with HealthNow policies and standards.Generate financial reporting, reconcile invoices and submit reports for the subsequent month.Respond to questions, resolving service, operational and process issues. Responsible for overseeing an RFP process resulting in the implementation of 15+ services and platforms. Successful in accomplishing a reduction in vendor spend of 17% through contracting and partnership with the Payment Integrity team on strategic development of internalization efforts.

Effectively manage and oversee staff while managing all tasks of medical claim production, check control functions, savings and recovery functions and customer service. Maintain a positive work environment that supports raising the level of employee performance through accurate assessment, coaching, skill development, recognition and if necessary, disciplinary action.Monitoring of real time call and claim center activity, provides real-time and historical data analysis while measuring teams productivity and efficiency. Develop daily action plans including analysis of inventories and work distribution.Responsible for generating monthly executive reports. Participate in unit staff meetings and share information and data as requested. Also attend various departmental meetings and act as a departmental liaison.Develop and implement automated solutions for manual tasks and process improvements.Act as a change agent for the department and overall company success.

Supervising employees, managing and oversee the operating processes for the timely issuance of Passports.Planning, directing, and coordinating the daily activities of mail open, cashier, image capture (scanning), image review, data entry, book-print, quality control, and PRISM (passport record scanning) for Passport production.Hire, conduct performance reviews, document performance issues and coordinate with HR to provide documentation in addressing employee performance, attendance, conduct issues or terminations. Responsible for monitoring and evaluating quality of work being completed by employees to ensure employees are properly trained, meeting production standards, following internal controls procedures and producing quality work.Develop, implement and overseeing the training of staff.Verifying adherence to all department and agency security regulations and internal controls.Facilitate daily team meetings with an emphasis on performance enhancements, best practices, problem solving and conflict resolution.

Effectively manage and oversee staff while managing all tasks of medical claim production.Partner with site leadership to maximize processor performance and goal attainment at individual, team and site level.Experience working in several Six Sigma projects.Work closely with the site Director to implement, coordinate both strategic and tactical plans to enhance operational and service performance while protecting health information and maintaining confidentiality.Ensure excellent performance of staff when servicing provider or customer contacts, by working with and leading teams to ensure efficiency and quality service.Facilitate daily team meetings with an emphasis on performance enhancements, best practices, problem solving and conflict resolution. Maintain a positive work environment that supports high performing teams and rewards people based on performance.Participate in salary budget discussions and decisions.