Vice President Claims- Self Funded Groups

Vice President, Claims – Self-Funded Groups

Major Responsibilities:

• Set up new medical, dental, and vision plans for self-funded groups or update existing plans.
• Oversee Claims Processors and the Reinsurance department.
• Handle special projects with vendors and process claims for multiple groups as needed.
• Communicate with plan sponsors, employees, and providers regarding claims and coverage questions.

Role Responsibilities:

• Build medical, dental, and vision plans in claims processing software for new groups and update current plans as necessary.
• Update plan documents and maintain the website for sponsors, employees, and providers.
• Supervise claims processors, reinsurance department, and check printing processes.
• Set up new groups with check printing vendors.
• Pull claims from the clearinghouse, distribute them to appropriate queues, and resolve any related issues.
• Manage medical review cases with vendors and communicate decisions to providers and employees.
• Enter updated W-9 information into the claims processing system.
• Address coverage and claims procedure questions for group sponsors, employees, and providers.
• Submit reports to clients and vendors and provide forms and claims-related materials as requested.

Additional Responsibilities:

• Process medical, dental, and vision claims for multiple groups as needed.
• Handle special projects regarding claim changes or issues.

Professional Qualifications:

Knowledge:

• High School Diploma or Equivalent (some college preferred).

Skills:

• Basic knowledge of laws and regulations related to benefit plans, including COBRA, HIPAA, and the Affordable Care Act.
• Strong analytical and critical thinking skills.
• Team player with a collaborative mindset.

Experience:

• Five (5) years of experience in benefits, insurance, or medical coding.

Technical Competencies:

• Proficient in Microsoft Office Suite.

Professional Competencies:

• Effective communication skills.
• Strong customer focus.