Director of Operations & Claims Administration

Overview

Birdsong Hearing Benefits LLC, is a hearing benefits manager that views hearing care as total care. As a third party administrator (TPA), Birdsong adjudicates claims and manage both claim activities and the contact center for our clients. Birdsong services as a first downstream entity to all contracts, providing hearing care services to health plans and clients.

Birdsong is seeking a Director of Operations and Contact Center to spearhead its claims, call center and operations activities for the hearing benefit manager and its clients. The Director of Operations will be a key member of the leadership team. This position actively participates in the oversight of the claims administration and contact service center. In conjunction with the Chief Operations Officer, the Director provides oversight into the development of strategies and processes, direction of staff, and execution of operational tasks within the scope of the operations unit. Key areas of responsibility include TPA services associated with hearing benefit manager role and oversight, audits, management of corrective action plans, internal audits, policies and procedures, continuity of care, call center operations, and key performance indicators associated with contract guidelines. The Director implements the execution of the organization's annual operational strategy with a focus on operational excellence and stellar customer service. The Director of Operations is tasked with managing the consumer and end-user journey encapsulating all experiences through Members and Customer Service functions, Operational Excellence /Continuous Improvement, and Operations.

By setting comprehensive goals and objectives, the Operations and Contact Center role leads and encourages maximum performance and dedication. This role is a high-visibility position, requiring effective communication skills by representing Birdsong and its subsidiaries, and its mission both internally and externally. The position works with leaders across the organization to implement strategies and carry out the value proposition of the organization through the operations and contact center activities. The Director of Operations drives a strong focus on consumer/member service, elevating the experience, operations, and strategy together, to strengthen and expand membership offerings. The Director has accountability for ensuring excellent end-to-end consumer/member/provider/payer experience, producing consumer/member/provider/payer value, applying best practices, improving operational effectiveness, encouraging innovation, and driving sustainable growth. The role will report to the Chief Operating Officer and will work collaboratively with the rest of the leadership team.

Responsibilities

Key Strategy & Execution
- Plays a key role in strategic planning as related to the operations, claims, and contact center management, while ensuring that Birdsong and its subsidiaries stay true to its mission, vision, and values.
- Acts as a strategic thinker on the leadership team and works closely with the team to ensure that business objectives are met.
- Collaborates with others to develop and implement plans for the operational infrastructure of systems, processes, and people, designed to accommodate growth objectives as prescribed by the consumer/member/provider/payer success in their journey.
- Works closely with senior and mid-level managers in operations management, ensuring participatory decision making and appropriate design and implementation.
- Coaches and develop management to ensure the team in operations are delivering against key business initiatives and maintaining accountability for key performance indicators (KPIs) of both the operations and contact center.
- Leads operations to provide exceptional consumer/member/provider/payer experiences resulting in increased consumer/member/provider/payer acquisition, retention, and satisfaction through implementing protocols in mission-driven success for the operations, claims, and contact center.
- Focuses on increasing core Membership renewals, using success metrics such as KPIs, increasing NPS.
- Demonstrates a willingness to take on new challenges, with an infectious positive attitude and endless energy
- Represents Birdsong with clients, prospects, and in other business partnerships / relationships with a polished, professional business acumen.
- Develops and implement strategies for EDI and encounters processing that align with organizational goals and regulatory requirements
- Leads cross-functional teams to assess, plan, and execute new business implementation and integration projects concerning EDI transactions, including but not limited to:
- 837: Health Care Claim
- 835: Health Care Claim Payment/Advice
- 270/271: Eligibility Inquiry and Response
- 276/277: Claims Status Inquiry and Response
- 834: Benefit Enrollment and Maintenance
- Collaborates with IT, operations, finance, and compliance teams to enhance data exchange processes and technology solutions; keeping abreast of continual changes and modifications of systems
- Establishes and maintains relationships with external/internal partners, payers, and vendors to facilitate seamless EDI transactions
- Monitors industry trends, best practices, and regulatory changes related to EDI and encounters to ensure compliance and operational excellence
- Provides training and support to staff on EDI processes and tools, fostering a culture of data integrity and accuracy
- Analyzes performance metrics and data reporting to identify areas for improvement and drive operational efficiencies
- Prepares and presents regular reports to executive leadership on the status of EDI initiatives and new business implementations
- Establishes and monitors key performance indicators (KPIs) to measure project success, identify improvement areas, and provide regular progress reports to leadership
- Demonstrates the ability to lead a team through problem-solving and creative solutioning
- Serves as the escalation partner for all technical project components, standards, business, and strategic objectives; ability to see arising issues, find resolutions, and recommendations for corrections
- Accountable for the development and implementation of policies, procedures, and standards of EDI and encounters for new market implementations
- Leads discussions with vendors and internal stakeholders on EDI and encounters requirements needed for implementation
- Facilitates comprehensive discussions with vendors and internal stakeholders to gather, analyze, and document detailed requirements for EDI and encounter implementations
- Works collaboratively to define project scope, address technical and operational needs, and establish clear timelines for successful completion
- Manages the overall testing of implementation as it relates to new client implementations, including EDI claims received from network partners and direct submitters, claims submitted via provider portals, and paper claims received via paper vendor, ensuring quality of data is maintained
- Responsible for coordinating UAT testing with internal quality assurance and vendors, developing comprehensive UAT test plans, monitor test execution, and issue resolution, coordination of UAT testing with BPaaS team including results, and provide final sign-off for production releases.
- In collaboration with vendor, manage department's tickets driving priority, timelines, and final approval to close.
- On a monthly basis, perform member eligibility audits comparing incoming plan data (834) to system data to ensure data integrity.
Operational Excellence
- Champions continuous improvement (CI) efforts through culture-focused team building, data gathering and analysis, problem solving, and application of methodologies for superior operational effectiveness, claims cleanliness, and contact center service.
- Motivates and leads high-performance management teams, while leading all employees to encourage optimal performance and dedication, as it relates to operational efforts.
- Oversees the design and delivery of skill and knowledge transfer to leaders and staff on specific principles, tools, and processes for continuous improvement (i.e., lean, six sigma), project management, and change management, where applicable and in conjunction with team leaders of such areas.
- Works collaboratively to develop and/or improve systems, processes, controls, and procedures that impact overall efficiency and productivity, reduce costs, increase revenue, and improve control measures, while ensuring excellent consumer/member/provider/payer operational experience, claims, and service.
- Responsible for financial budget and management of budget requirements.
- Responsible for key performance indicators and contractual KPI measures.
- Coordinates across operational business segments and functions to assure appropriate information flow and understanding of overall objectives.
- Consistently seeks to develop methods to improve quality, efficiency, and productivity, reduce costs, increase profits, or improve control measures.
- Works cohesively with client services for all new and existing implementations.
Consumer/member/provider/payer Operational, Claims, and Contact Center Experience
- Creates an effective and ongoing strategy for anticipating and responding to consumer/member/provider/payer need through superior operational hygiene, claims management, and contact center excellence.
- Understands claims and ancillary software systems for operational management, and defines unique strategies for potential efficiencies, higher level service delivery, and compliance click apply for full job details