Harbor Health is hiring a
Claims/Enrollment Operations Manager

Summary

Join Harbor Health as we build a fully integrated system that connects care to a better payment model that truly puts the human being at the center. We are looking for an experienced Claims/Enrollment Operations Manager to oversee the processing of transactional data on behalf of Harbor members.

Requirements

• 7 years of relevant healthcare experience, particularly with regard to health plan operations and technology
• Demonstrated success operating high-growth companies
• Data analysis skills including the ability to pull data from source systems
• Demonstrated creativity in identifying and implementing solutions to complex, ambiguous issues
• Ability to act as a team player
• Ability to manage outside vendor relationship
• Have the ability to partner in the development, management and operationalizing processes and workflows to maximize efficiencies

Responsibilities

• Review and validate System Configuration of Benefits, Claims and Member
• Validate and approve TPA’s UAT test cases
• Create, process, and validate claims and member test cases
• Review and approve claims and enrollment processing instructions
• Coordinate development of Operational Reports with TPA and Harbor Health
• Review and approve EOB, EOP, Claims and Member processing codes
• Daily review of Claims and Members processing statuses. Identify any issues and coordinate with TPA the resolution of issues
• Sampling review of claims processed, member updates, ID cards, letters, EOBs and EOPs on vendor’s sites. Identify and issues and coordinate resolution with appropriate parties
• Coordination with appropriate partners of any member/provider inquiries, complaints, group, or state audits
• Approval of designated “high dollar” claims
• Audit a sampling of claims in finalized status. Identify any issues and coordinate with TPA on resolution and training
• Track and report on assigned implementation milestones and tasks
• Coordinate, audit, and approve TPAs security roles, functions, and people
• Other duties as assigned

Preferred Qualifications

• Strong knowledge of state claims/members processing rules and regulations
• Experience implementing and operating delegated TPA, UM, UR, credentialing and related functions
• Knowledge of benefit plans design, EOC and other applicable documents
• Experience developing and administering value-based payment arrangements a plus

Benefits

This is a remote role