Director of Operations

The Director of Operations will be accountable for the Claims, Claims Acquisition, Enrollment, and Member Advocate teams working with PBA’s leadership team to set the course for PBA’s future. Must be an outgoing business leader who can observe, analyze, and continually improve the operation to ensure it runs as efficiently as possible for PBA's success. This role reports to the COO/Integrator. Please see below for a more in-depth overview of daily responsibilities and skills required for this position.

Responsible for

• LMA (Lead, Manage and support a culture of Accountability) using the EOS model.
• Developing, mentoring, and evaluating Operations staff including, but not limited to, annual reviews and Quarterly Conversations
• Oversight and accountability of the entire Operations team which includes:
  • Member Advocacy (Customer Service)
  • Claims Acquisition
    • Claims Prep
    • PPO Liaison
    • Provider Maintenance
    • Mail Room
  • Enrollment
  • Claims
    • Claims Processing
    • Training/Auditing
    • Excess stop loss claims
    • Plan Loading
    • Medical Management navigation between PBA and UR Vendors
• Reporting department activity to Leadership team and COO/Integrator on a weekly basis
• Working with Leadership team to stay in front of governmental compliance issues and their implementation on behalf of clients.
• Coordinating resources and setting accountability within the department to accommodate the constantly changing environment.
• Applying observations and feedback to continually improve PBA’s operation
• Team building
• All other duties as assigned.

Requirements for this position

• 5+ years managing, supervising, coaching, and directing a similar service based or claims operation.
• Claims processing knowledge a plus.
• Third Party Administration. Stoploss experience or knowledge a strong plus.
• Javelina claims system experience or knowledge a strong plus.
• Senior level organizational, analytical and accountability skills are necessary.
• Effective verbal and written communications skills necessary to lead and grow all team members while supporting our clients and brokers needs.
• Demonstrated ability to get results through team members and management.
• Adaptability to new concepts and systems
• Problem solver and critical thinker
• Open minded and desire to learn, grow and receive feedback in a welcoming way.
• Must be able to represent PBA’s Core Values and business procedures to vendors, brokers, and clients.

Essential functions statement

• This position may require you to be in the office up to two days a month for meetings, training, etc.
• The person in this position frequently communicates with co-workers, subordinates, customers and vendors via phone and email.

Member Advocate

Responsible for

• Handling inbound phone calls and provide quality customer service to callers.
• Placing follow up calls to members and providers.
• Responding to portals and e-mails.
• Maintaining a work knowledge of plan benefits.
• Suggesting process improvement ideas.
• Going the "Extra Mile" when necessary.
• Performing other duties as assigned to support PBA’s Mission, Vision and Core Values.

Minimum job requirements

• Strong verbal communication skills along with being an active listener.
• TPA/Insurance Company environment or medical billing office experience preferred.
• Proficient in Microsoft Office Suite products.
• Must be able to maintain a positive work atmosphere by behaving and communicating in a manner so that you get along with customers, clients, co-workers, and management.
• Must be a self-starter who is organized, sets priorities and manages time effectively.
• Ability to quickly learn and adapt to new concepts/systems.
• Ability to interface with various levels of the organization.

MNE Appeals Specialist

The MNE/Appeals specialist is responsible for reviewing incoming documentation received in the Coordinated Care department while serving as a liaison between PBA and its Utilization and Care Management partners. This position will have an in-depth knowledge of claims as well as strong written and verbal communication skills. This individual reports to the Quality Supervisor of the Coordinated Care department. Please see below for a more in-depth overview of daily responsibilities and skills required for this position.

Responsible for

• Review incoming medical records and determine if medical necessity has been submitted.
• Review incoming appeals.
• Determine if PBA can respond based on the plan document wording.
• Monitor and work the internal Claims Research Email box for Urgent and/or status requests.
• Send records to the appropriate UR vendor for review.
• Document JV patient notes clearly for all PBA departments.
• Document patient notes, update excel spreadsheet case.
• Create and send out letters to provider and copy in employee of the review/appeal determination.
• Send WORD document letter to mailroom to print and mail to employee.
• Upload copies of letters to JV system.
• Fax letters to providers.
• Notify the assigned analyst of any claims to be reprocessed.
• Ensure quality of workflow between PBA and UR/CM/DM partners.
• Manage the appeals process to IRO level.
• Other duties as assigned.

Minimum job requirements

• Knowledge of ERISA and non-ERISA/ Grandfathered and non- grandfathered plans.
• 2+ years prior knowledge/understanding of claims.
• Excellent oral and written communication skills, Friendly, compassionate manner
• Thorough understanding and applying Plan language.
• 2+ years of prior work with CPT/ICD 10 codes.
• Javelina claims system experience a plus.
• PC, keyboard skills and use of Outlook, Word, Excel, with the ability to master additional information.
• Must be able to maintain a positive work atmosphere by behaving and communicating in a manner so that you get along with peers, subordinates, customers, clients, and management.
• Result oriented with a strong customer focus.
• Good organizational skills.
• Multi-task and prioritize projects throughout the day.
• Ability to work and interface with various levels of the organization.

Physical demands

• This is largely a sedentary role which requires the ability to sit for long periods of time.
• To perform the physical requirements of the position, this person must be able to possess manual dexterity in their hands.

Essential functions statement

• The person in this position will work in the office up to 4 times per month. The other days can be worked either in the office or remotely.
• The person in this position frequently communicates with co-workers, subordinates, customers and vendors via phone and email. The person in this position must be able to exchange accurate information in these situations.

Stop-loss Claims Coordinator

The ideal candidate for this role will possess great attention to detail to ensure efficiency and accuracy for filing stop loss/reinsurance claims, as well as the ability to communicate with various internal and external customers.

Responsible for

• Filing of initial, subsequent, and final claims submissions to excess carriers with accuracy and timeliness.
• Maintaining excess files in a neat and orderly manner
• Maintaining the Claims Log accurately and as directed
• Send High Dollar Notifications to the excess carriers.
• Follow-up on all outstanding claim submissions every 2-3 weeks as needed.
• Reviewing the Excess Hold Report on a daily basis.
• Handling of Priority List/Month End Renewals with accuracy and provide proper notification to Accounting Dept of check batch lock-ups.
• Reviewing and responding to inquiries made by clients, brokers, and PBA staff in a timely manner.
• Reviewing/assisting carriers on questions or issues that may arise from submissions.
• Forward copies of cover letters and reimbursement checks/letter to Excess Clerical Support for forwarding to certain brokers/clients.
• Assist Customer Service/Claims Department with questions concerning excess files.
• Review refunds to determine payment outcome.
• Comply with data integrity and security policies
• Perform other duties as assigned to support PBA’s Mission, Vision, and Values
• Must be able to represent PBA’s Core Values to vendors, brokers, and clients.
• Generate month end reports
• Other duties as assigned.

Minimum job requirements

• Ability to maintain a positive work atmosphere by behaving and communicating in a clear and concise manner so that you get along with customers, clients, co-workers and supervisors.
• Must have a performance record that demonstrates a professional and responsible work ethic.
• Strong stop loss/reinsurance claim knowledge/understanding.
• Attention to detail is required to ensure accuracy.
• Must have basic knowledge of Word and Excel programs.
• Excellent organizational and communication skills.
• Ability to work independently and as part of a team.
• Ability to adapt to new concepts and systems.
• Ability to prioritize multiple projects throughout the day.