Responsible for the administration of $750 million in annual health care expenditures to 60,000 beneficiaries. Responsible for managing all in-house operational activities as well as those under contract with outside vendors. Coordinates and oversees the activities of all internal Operations and vendors’ staffs (over 250 people) to ensure that existing programs are operated in an efficient and effective manner and that new programs are implemented in a timely fashion. Serves as focal point for all Funds’ activities relating to the operational responsibilities of staff and outside vendors. Ensures that all claims processing, cost management, call center, HCPP compliance audits, managed care, network development, eligibility services and operations activities are carried out in compliance with all applicable regulations, including administrative services agreements, the Funds’ administrative policies as well as the Funds’ Plans and Trusts. Ensures that all Funds’ programs are operational, and that budget guidelines are met for ongoing programs. Ensures that all new programs are administered in a similar manner. Assumes the duties of the Director of Operations and in his/her absence.
PRIMARY DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Directs and oversees all operational activities pertaining to claims processing, managed care programs, call center performance and network development activities for medical and vision benefits, to ensure that all vendors and subcontractors perform the services as outlined in the current administrative services agreements and upholds the Funds expectation of excellence. Coordinates the Funds’ response to CMS relating to the audit of the annual cost report. Organizes a team that collects and reviews all medical records and any other information needed to support that the adjudication of claims meets CMS’ guidelines. Also initiates quality improvement to correct any deficiencies discovered because of the audit.
Provides direct support to the Eligibility Departments Deputy Director that would help contribute in any way to the improvement of the quality and production of pension and health applications. Provides daily communication support between the Operations and Program Development Department and other departments within the Funds. Works closely on a daily basis with the Deputy Director of Eligibility Services Department.
Monitors and reports to Trustees on all program performance measures under the administrative agreements.
Monitors the Funds’ privacy policies and directs department personnel efforts who monitor, implement, and maintain compliance with HIPAA rules and regulations.
Assumes a vital role in the transition of new groups that are enrolled into the health plans due to bankruptcy or through collective bargaining.
Coordinates all program changes with internal staff and vendors to ensure efficient and effective implementation of Medicare program changes, new cost management initiatives, or managed care systems/networks implementation.
Motivates his/hers direct reporting staff, ensuring they clearly understand the Funds’ health plans goals and philosophy. Monitors and reports on administrative costs relative to the claims processing activities and other program operation functions. Reviews the department’s budget and monitors expenditures. Manages senior managers and program managers in the department and is responsible for the overall direction, coordination, and evaluation of this unit. Carries out managerial responsibilities in accordance with the Funds’ policies and applicable laws.
Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Assumes the duties of the Director of Operations and Program Development in his/her absence.
Responsible for adhering to all Funds’ policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security and use of protected health information.
Manages eight managers and/or senior managers in the Operations and Program Development Department, and is responsible for the overall direction, coordination, and evaluation of the department. Carries out managerial responsibilities in accordance with the organization’s policies and applicable laws.
In-depth knowledge of health care insurance industry, including claims processing, cost management, Medicare, and health policy. In-depth understanding of programs to manage contractor’s systems planning and development strategies. In-depth knowledge of the administration of benefit plans, ERISA, COBRA, Qualified Domestic Relations Orders, and appeals as well as applicable Medicare and Black Lung laws and regulations. General knowledge of the insurance and coal industries. Understanding and working knowledge of in-house systems and eligibility/pension processes and guidelines.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
Bachelor’s degree (B. A.) from four-year college or university; PLUS, six to eight years related experience and/or training; or equivalent combination of education and experience.
Ability to read, analyze, and interpret complex material (legal documents, government regulations, etc.). Ability to represent the Funds in responding to inquiries or complaints from beneficiaries, regulatory agencies, or members of Congress, or of the business community. Ability to write with precise language to communicate complex information (detailed business reports, policy statements, etc.) that conforms to prescribed style and format. Ability to effectively present information to internal staff, top management including the Executive Director and Trustees, outside contractors such as consultants, physicians and Third-Party Administrator, and beneficiaries.
Ability to apply advanced mathematical, financial or statistical concepts to analyze complex information such as designing or developing statistical or financial models or reports.
Ability to define problems, establishes facts, provide creative solutions and support insights into highly complex problems.
CERTIFICATES, LICENSES, REGISTRATIONS
None required for this position.
OTHER SKILLS AND ABILITIES
Requires computer skills at an intermediate level, such as generating word processing letters/reports, intermediate spreadsheet usage, and/or operating printers and other peripheral devices.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to stand and walk. Specific vision abilities required by this job include close vision, and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Occasionally requires working overtime or hours significantly beyond the normal work day/work week, traveling during and outside of business hours and being on call in excess of regular number of business hours. Frequently requires working under tight time constraints. Constantly requires working in an area in which the work product is subject to very precise measures of quantity and quality.
The noise level in the work environment is usually moderate.
Moderate travel and offsite training are necessary.
COMPLETE BACKGROUND CHECK REQUIRED.
Employee assistance program
Flexible spending account
Paid time off
Professional development assistance