Responsable de Missions Audit clé dans l'audit légal et contractuel chez Exco Socodec. Supervisant les équipes et assurant la qualité des travaux, avec un portefeuille diversifié de clients.
About the role
- Manager of claims at Centivo overseeing audit, appeals, and quality. Ensuring compliance and operational efficiency in healthcare claims administration.
Responsibilities
- Ensure claims, appeals, and adjustments are processed accurately and in accordance with benefit plans, pricing agreements, authorizations, and regulatory requirements, intervening as needed to resolve issues and escalations.
- Oversee and manage claim inventory against established service-level agreements (SLAs), setting priorities for team members.
- Direct, coach, and develop staff, ensuring proper application of client benefit plans and achievement of quality and production standards; establish and monitor performance plans for team members falling below expectations.
- Establish clear accountability for training and onboarding outcomes, ensuring skill development is treated as essential to core operations.
- Lead the development and refinement of operational and quality KPIs across CMAS functions, with particular focus on day-to-day performance, appeals timeliness, and regulatory compliance.
- Review, analyze, and report on operational performance, including claim inventory, production volumes, turnaround lag, and quality metrics, and communicate trends and risks to department leadership.
- Develop and execute work plans to reduce claim inventory and improve service performance, including oversight of overtime usage to ensure cost effectiveness.
- Identify and drive process improvement opportunities, including workflow standardization, automation, and AI-enabled enhancements, to improve efficiency, quality, and turnaround times.
- Oversee the development and enforcement of policies and procedures to ensure claim standards are administered consistently; monitor team compliance and address gaps.
- Set team goals aligned with departmental and organizational priorities, providing ongoing feedback and formal performance evaluations to support individual growth and accountability.
- Maintain accountability for team morale and engagement, fostering collaboration by involving staff in problem-solving and solution design.
- Serve as the CMAS liaison on projects and initiatives, including claims testing and support for system implementations or upgrades.
- Partner cross-functionally to support client issue resolution and implementation efforts, ensuring CMAS considerations are incorporated into broader claims workflows.
- Act as a point of contact as needed for clients, vendors, or providers requiring CMAS relationship ownership.
- Perform other duties as deemed essential and necessary.
Requirements
- Bachelor’s degree or equivalent work experience required.
- 5+ years of experience in healthcare claims administration; self-funded and/or TPA experience strongly preferred.
- Demonstrated experience managing teams involved in claims audit, appeals, recovery, quality, or escalations.
- Strong understanding of benefit administration, claims adjudication, and regulatory requirements.
- Experience managing operational metrics, quality programs, and service levels in a regulated environment.
- Prior experience with highly automated and integrated claims adjudication systems (e.g., Javelina, Health Rules Payer, or similar).
- Strong communication, organizational, analytical, and problem-solving skills.
- Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint.
Benefits
- Offers Equity
- Offers Bonus
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