This role is remote, but must sit in Ohio.
The Claims and Encounter Administrator is responsible for ensuring prompt and accurate provider claims processing and accurate and timely encounter reporting to ODM. Health plan liaison to claims processing and enrollment submission functional areas. The Claims & Encounter Administrator also maintains oversight of functions in local service center, including but not limited to customer service, claim, provider services, complaints, grievances, and appeals, implementation, and/or plan sponsor operations. Executes local strategic and operational plan in support of business segment customer service objectives and initiatives. Plans, directs and implements procedures that will assure a high level of customer access and satisfaction. Responsible for the quality and effectiveness of own team and related teams, identifying and resolving technical, operational and team problems.
- Plan liaison with segment claims and encounter teams; working cross functionally with operations to resolve claim issues impacting encounter performance to ensure contractual requirements are met. Facilitate performance review meeting with segment claims and encounter teams.
- Oversees the operations in a local service center handling a customer service function, which may include claims, member or provider services, billing, enrollment, accounts receivable and implementation services.
- Assist with developing billing guides for various provider types and act as subject matter expert for claim submission requirements to ensure encounter acceptance including provider education and training sessions.
- Develops, monitors, and reviews performance reports and service performance trends for each account against the plan and recommends specific actions or remedies as necessary.
- Develops and maintains strong collaborative relationships within operations as well as with patient management, Sales and Marketing, PSS, Underwriting, Utilization Management, and network management in establishing appropriate service level agreements.
- Creates and maintains tools, job aids, and training materials to help employees in their efforts to resolve issues and improve their relationship with customers.
- Collects, analyzes and reports on operations information in support of process, systems, and policy redesign.
- Effectively applies and enforces Aetna HR policies and practices, i.e., FMUEML, Attendance, Code of Conduct, and Disciplinary Guidelines.
- Effectively manages cross-functional projects that support the business strategy.
Specific to the OhioRISE contract, responsibilities include but are not limited to:
Develop and implement claims processing systems capable of paying claims in accordance with state and federal requirements, including resubmissions and overall adjudication of claims;
Develop processes for cost avoidance;
Ensure minimization of claims recoupments;
Ensure claims processing timelines are met; and
Ensure ODM encounter reporting requirements are met, including sufficient staff to ensure the submission of timely, accurate, and complete encounter data to ODM.
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
COVID-19 Vaccination Requirement
- Claims processing experience in a health plan is required.
- Encounters experience is required.
- 5+ years’ experience in managing high volume transaction processing, financial management, project delivery, production, systems analysis and application program development.
- Demonstrated negotiation skills and problem-solving skills.
- Multiple years proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes.
- Experienced working with vendors.
- Customer service experience.
- Demonstrated proficiency with personal computer, keyboard navigation skills and with MS Office Suite applications (Outlook, Word, Excel, PowerPoint, SharePoint, etc.)
- Ability to travel in-state as needed. Must have reliable transportation, valid/active driver's license, and proof of vehicle insurance.
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
- Previous claim processing and/or encounter submission
- Healthcare experience preferred. Managed care, Medicaid, and Behavioral Health experience is a plus.
- Proven strong leadership skills managing large high-performance teams.
- Strong verbal and written communication and interpersonal skills.
- Advanced degree preferred.
Bachelor's degree in a closely related field, or equivalent combination of education and experience.
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.