Senior Manager, Claims Service Operations

1. Leads a team of approximately (10-15) internal claim specialists and onshore/offshore vendor resources for Aetna Signature Administrators and Meritain claim processing. Monitor team performance, set goals, and manage daily production. Provide training, coaching, and development opportunities for team members. Foster an intentional, purpose-driven culture by promoting shared values, encouraging collaboration, and creating an environment where team members feel engaged, empowered, and aligned with the organizations mission and goals.

2. Responsible for delivering exceptional customer experiences by ensuring each interaction is professional, efficient, and customer focused.

3. Oversight of claim processing: application of provider contracted rates; conversion of paper claims to EDI; supporting and coordinating the flow of claims through the operational process, which may involve working with multiple departments

4. Responding to inquiries from customers and other stakeholders regarding urgent processing, pricing disputes, and escalated issues.

5. Responsible for collaborating with the Quality Management team and training program for service operations.

6. Liaison with Aetna Network Management to manage and resolve large scale claim pricing issues resulting in rework, payment verification, and provider settlements.

7. Monitoring key performance indicators (KPIs) and identifying areas for improvement in the claim's operations process. Understanding key drivers that affect performance across service operations to bring improvements to the overall customer experience. Diagrams and evaluates existing processes, analyzes data, and develops future state direction that maximizes efficiency and technology.

8. Builds and maintains positive, productive relationships with internal and external constituents that influence customer outcomes at all organizational levels necessary to accomplish goals.

9. Adhering to company policies, procedures, and relevant federal and state regulations governing healthcare claims. Ensuring data accuracy and security in accordance with privacy regulations (e.g., HIPAA). Staying up to date on changes in healthcare regulations and their impact on claims processing.

10. Stay current with industry trends and technologies related to healthcare claims processing and implement new solutions as needed. Required Qualifications

• Eastern or Central time zone candidates (willing to work Eastern hours)
• Minimum 5+ years' experience in a service operations environment; Healthcare experience and demonstrated working knowledge of claim processing.
• Experience in a leadership role, minimum 3 years preferred.
• Demonstrated ability to listen skillfully, collect relevant information, build rapport, and respond to customers in a compassionate manner.
• Demonstrated independent decision-making and the ability to navigate ambiguous situations while adhering to established guidelines.
• Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
• Ability to inspire, develop, and guide a team toward achieving goals.
• Strong verbal and written communication skills to convey expectations, provide feedback, and collaborate effectively. Proficient conflict management skills to resolve issues in a stressful situation.
• Experience tracking key performance indicators (KPIs) and using data to drive results.
• Comfort in navigating change and guiding a team through transitions.

Education:

Bachelor's degree preferred/specialized training/relevant professional qualification.Pay Range

The typical pay range for this role is:$67,900.00 - $182,549.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program.Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 05/01/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.