Coverage Review Operations - Director - Hybrid

Coverage Review Operations provides a variety of clinical services that help health plans and pharmacy benefit managers protect patient health and safety and improve affordability while reducing unnecessary costs. The Director is responsible for the daily oversight and management of an expansive team (500+ FTEs) consisting of internal and onshore and offshore supplier representatives. This role is responsible for day-to-day operations in alignment with volume and channel forecasts balancing client Performance Guarantees and Service Level Agreements as well as helping to formulate and execute strategic operations roadmaps. This includes partnering with outsourced leadership to ensure that our Global Service Partners (GSP) are motivated and receive proper direction to achieve top performance against quality, operational efficiency, and adherence to policy, procedure, and defined process, delivering optimal provider and member experiences.

Primary Responsibilities

• Provides direction and is accountable for the execution of prior authorization reviews and direct member reimbursement claims in accordance with client benefit intent policies and regulatory requirements.
• Effectively communicates to team members with varying levels of Coverage Review and Direct Member Reimbursement subject matter expertise.
• Gathers insights and makes data-driven decisions while understanding future planning of the areas supported to ensure a true strategic partnership delivering to our most critical stakeholders.
• Owns operational results and outcomes.
• GSP management with accountability of various functions such as operational performance (quality, productivity), achievement of service level agreements, alignment of staffing models and training plans, and review/ reconciliation of monthly invoices.
• Accountable to continuously assessing Business Process Outsourcing (BPO)/GSP footprints both onshore and offshore, current/ future strategic relationships, and business continuity planning.
• Sets goals aligned to the Enterprise strategy and motivates a team of people with diverse skills, responsibilities, and geographic locations towards these goals.
• Ensures organizational alignment through cooperative development of individual and departmental objectives and provides individual, organizational, and global supplier partners feedback on performance on a continuous basis.
• Interacts with and influences senior leadership. Makes decisions that have a short to medium-term impact across the function as it relates to both our internal stakeholders and global service partners.
• Attracts, retains, and develops top talent.
• Provides strategic thought leadership and drives continuous improvement to advance provider and member experiences/ partnerships, leading to reduced expense and increased customer satisfaction.
• Identifies opportunities for process improvement and works with partners to implement.
• Provides insights into the creation of a multi-year people, process, and technology roadmap.

Key Qualifications

• Bachelor’s Degree; Advanced degree strongly preferred.
• 8 plus years of relevant experience; to include experience developing and executing core operations functions and strategies.
• Experience with leading a large team overseeing broad scale operations with strong cross-functional partnerships (Global supplier partners/ BPOs, HR, workforce management, Account teams, technology, shared services such as quality, training, project management, etc.).
• Demonstrated effectiveness working in a highly matrixed organization.
• Ability to manage change, timelines, and balance multiple deadlines in a very fast-paced environment.
• Advanced problem-solving skills and ability to work collaboratively through complex matters with innovative solutions.
• A passion for employee engagement and leadership development.
• Strong business and financial acumen.
• Strong written and verbal communication skills, to interact effectively with all levels of management including executives, employees, customers, technology staff, and Global Service Partners.
• Considerable knowledge of and experience in managing day to day operations and staffing needs with the ability to prioritize multiple projects.
• General understanding of healthcare and health insurance businesses and regulatory/CMS guidelines.
• Ability to think and act strategically and proactively. Proven track record of success in senior leadership positions.
• Serves as an advocate and change agent, influences courageously at all levels of the organization.
• Anticipates internal stakeholder and external client needs, investigates the underlying cause(s), and identifies short- and long-term solutions.

CRITICAL LEADERSHIP COMPETENCIES:

• Delivers Results – Pushes team and cross functional partners to deliver needed results in tough circumstances and expedited timelines.
• Builds Effective Teams – Builds strong identity teams that apply their diverse skills and perspectives to achieve common goals.
• Manages Complexity – Makes sense of complex and sometimes contradictory information to effectively solve problems.
• Manages Ambiguity – Operates effectively and drives work forward even when things are not certain or there is no clear way forward.
• Collaborates – Quickly builds partnerships and works collaboratively with others to ensure progress.