Individual & Family Plans (IFP) Claims Strategy and Payment Integrity Senior Manager - Remote - Cign

The Claims Strategy and Payment Integrity Senior Manager will play an important role in our Affordability strategy by providing claim payment oversight for the Individual and Family Plans (IFP) segment.

This individual will be responsible for identifying and driving claim payment integrity savings initiatives, monitoring and driving improvements in overall claim operations performance , and will assist in defining the strategic vision for IFP claim operations (claim platform, claim operations structure, etc.).

This role requires a self-starter who can work closely with Claim Operations, Claim Utilization Management, Provider Operations, Product, IFP's Total Cost of Care team, IFP's Risk adjustment team, and other matrix partners to improve affordability within the segment.

This individual will be able to align IFP claim administration activities against current industry policies/standards (especially IFP/Medicare/Medicaid).

Additionally, this individual will lead a small team and report directly to the IFP Senior Director of Operations.

The role is designed for an individual who enjoys the challenge of working in a fast-paced environment with the ability to prioritize and influence key deliverables to deliver maximum impact.

Core Responsibilities:


* Liaison for Claim Operations and lead for claim administration.


* Collaborate with financial risk and analytics team and other partners to establish and/or monitor reports and analytics to identify and remediate spend leakage


* Drive delivery of solutions to prevent claim overpayments, unnecessary claim spend, and ensure timeliness and accuracy of claim administration.


* Evolve SLAs and oversees business partner claims processing and auditing to ensure SLAs are met, inclusive of accountability for Claims Monthly Operating Review, Claim Accuracy workgroup, and Claim Payment Integrity workgroup.


* Represent IFP in claim payment policy, process, and technology solutions to ensure IFP's unique needs are met


* Oversee the development and implementation of internal/external controls to ensure administrative cost-effectiveness, accurate and correct coverage determinations


* Review and interpret operational metrics (i.e.

% pend, denied, paid, case mix, catastrophic claims expense, etc.) to assess need for procedural revisions and enhancements; participate in the design and implementation of specific systems to enhance claim adjudication processes.


* Have an excellent grasp of the claims system and overall workflow


* Keep up to date with carrier/coding/billing rule changes to ensure compliance with state regulations and/or provider contracts.

Support operations application of rules to apply for pre and post pay claim edits and recovery identification and pursuit.


* Support development and implementation of long term claim operations strategic roadmap inclusive of claim platform, claim policies and processes, and claim operations model.


* Lead, coach, ...