Manager Of Claims Adjudication - Department Of Family Medical Leave

State Of Massachusetts Boston , MA 02298

Posted 2 months ago

The Department of Family Medical Leave's (DFML) mission is to ensure that the workforce of Massachusetts is healthier, more productive, and enjoys a better quality of life. Our program, providing paid family and medical leave benefits to the working people of Massachusetts, will impact hundreds of thousands of lives every year. In order to maximize our impact our claims process needs to be efficient, effective and simple to understand.

The Manager of Claims Adjudication will be responsible for developing and continuously improving claims processes to inspire confidence that our payments are going to the right people in predictable timeframes. Working hand-in-hand with our technology vendor, the Manager will design business process flows for our claims adjudication staff and ensure our processes are implemented with fidelity.

Duties and Responsibilities:

  • Develop and formalize business processes for claims adjudication.

  • Support the implementation of the benefits technology solution through mapping and documenting processes to achieve business objectives.

  • Develop communication documents for internal and external stakeholders to understand the parts of the process relevant to them.

  • Monitor the implementation of business processes to ensure fidelity.

  • Serves as a technical expert and collaborative partner to stakeholders (employees, employers, medical providers, DFML personnel, DFML call center personnel and third party vendors, among others) to build strategic and tactical plans for DFML benefits administration and adjudication.

  • Executes on strategy and drives tangible claims results through continuous improvement in the claims process and a commitment to the claims adjudication process.

  • Leads a team of internal and external claims professionals to ensure the unit is efficiently resolving claims matters through enabling legislation and regulations and through established best practices, accurately reserving in a timely manner, coordinating payments, evaluating reduction and offset opportunities with other state agencies, private insurers and employers and making eligibility determinations while maintaining a commitment to outstanding customer service and achieving compliance goals.

  • Provides guidance, leadership, and/or technical expertise for claim benefit determinations and special projects as necessary.

  • Works closely with claims analytics, employers, human resource professionals, program administrators, finance, actuaries, internal & external attorneys to identify opportunities and develop and implement solutions that drive optimal outcomes.

  • Collaborates with internal partners, and use of data & analytics, in broadening DFML's development efforts.

  • Oversees the selection of top talent, delivers continuous coaching, understands and applies tools and processes to reinforce behaviors that ensure service excellence, and holds others accountable for the development of their people.

  • Inspires and motivates the team to execute, track progress, and continuously improve to achieve plans.

Preferred Qualifications:

  • Experience with professional leave administration and related technologies (3-5 years)

  • Vendor management experience

  • Experience or familiarity with agile project management methodologies

  • Experience with contact center oversight and continuous improvement

  • Bachelor's degree plus 5 years of progressive work experience in any of the following or a combination therewith; medical, professional liability, short term, long term disability claims

  • 5 years experience handling claims under policies issued through a Program Administrator

  • Advanced analytical and problem solving skills

  • Strong knowledgeof systems and claims operations

  • Superior communication and leadership skills

MINIMUM ENTRANCE REQUIREMENTS:

Applicants must have at least (A) five (5) years of full-time or, equivalent part-time, professional, administrative, supervisory, or managerial experience in business administration, business management, public administration, public management, clinical administration or clinical management of which (B) at least one (1) year must have been in a project management, supervisory or managerial capacity or (C) any equivalent combination of the required experience and substitutions below.

Substitutions:

I. A certificate in a relevant or related field may be substituted for one (1) year of the required (A) experience.

II. A Bachelor's degree in a related field may be substituted for two (2) years of the required (A) experience.

III. A Graduate degree in a related field may be substituted for three (3) years of the required (A) experience.

IV. A Doctorate degree in a related field may be substituted for four (4) years of the required (A) experience.

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.


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Manager Of Claims Adjudication - Department Of Family Medical Leave

State Of Massachusetts