Vice President-Beacon Direct Services #65848
The Vice President Beacon Direct Services (BDS) is a senior management position reporting to the president of Beacon Health, LLC. The VP leads operations for all Beacon Direct lines of business while providing guidance and strategic support to the key functional areas of the company. The VP of Beacon Direct Services is responsible for all Third-Party Administrator duties including; the provider network, network credentialing, claims payment, customer service and assuring the transfer of data to sales, marketing, finance, IT, provider relations and care management. The VP of Beacon Direct Services supports audit activities and participates in system-reporting development and presentation. While serving the President and Board of Directors, the VP assures that the systems operational strategy is executed professionally and in a timely manner.
The VP of BDS will directly manage a team of professionals including functional areas of, Payor Credentialing, Wellness and Network Development and Provider Contracting, including Account Executives and Sales.
Reports to: President, Beacon Health, LLC
•Responsible for an effective relationship with the claims processing vendor including document maintenance, payment accuracy, process standards and performance reporting.
•Directs the hiring, training and supervision of department management and staff.
•Responsible for oversight of plan document and loading functions. This includes the maintenance of client payment protocols and provider allowance schedules.
•Provides oversight of medical-claim appeals and directs the appeal process. Also responsible for reporting the status of disputed claims to clients, carriers and appropriate company personnel.
•Establishing relationships with medical review organizations and directs the decision to access outside services to review evaluations. This is all done in collaboration with Beacon Health's Medical Director of the Health Plan and Director of Provider Network Management and other subject matter experts as appropriate.
•Coordination of client claim reporting with sales, marketing, care management services, finance and legal departments. This includes data collection and coordination with PBM vendors, Health Reimbursement Account vendors, predictive risk indexing firms, underwriting carriers and appropriate company staff. Coordinates account management annual processes, including open enrollment; website interfaces, etc.
•Monitor federal and state regulations regarding balance billing or surprise billing and ensure that Beacon Direct customers are incompliance with rules. Take appropriate steps to ensure that members understand the steps necessary to avoid surprise billing.
•Responsible for Beacon Directs customer service operations- defined as those daily functions directly serving claimants, beneficiaries and provider representatives. The operation supports client and provider relationships through its call center activity whether internal provided or contracted externally. Responsibilities include staff and management training along with daily operational management. This includes responsibility for oversight of sub-contracted customer services related to TPA functions.
•Supervises the development and maintenance of customer service reporting and assures performance reports- including time to answer, first time resolution and other key measurements, are regularly provided to the management team. Works with sub-contractor to ensure timely reports are accurate and available.
•Directs the payor credentialing function assuring an accurate database of provider information and responsive reporting capabilities.
•Oversees Beacon's largest data set as it relates to provider rosters, credentialing and reporting requirements (eVips).
•Supports monthly Credentialing Committee.
•Responsible for timely interactions with claim vendor to identify and resolve any denials or authorization issues related to provider credentialing.
•Assures timely & accurate upload of credentialed providers to claims vendor.
Network Development & Provider Contracting
•Directs/Develops overall physician and facility network development strategy prioritized around providing high value-based care, including expansion of wellness and behavioral health statewide network.
•Together with the Director of Provider Network Management serves as the primary liaison with the provider network on a range of operational issues, supporting Beacon Health contracting activities and building positive relationships.
•Provide direction and support to the Director of Provider Network Management and external consultants in the development of provider networks.
•Oversee the periodic analyses of the provider network from a cost, coverage, and growth perspective. Provide leadership in evaluating opportunities to expand or change the network to meet Company goals.
•Manage budgeting and forecasting initiatives for product lines to networks costs and provider contracts.
•Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations
•Support market expansion and Medicare Advantage activities by leading provider contract analysis related to due diligence.
•Collaborate with senior leadership on key provider relations and strategy.
•Assures timely and accurate upload of provider contracts to claims vendor.
•Oversees eVips contracting database to ensure proper/accurate use of templates, liability coverage, rates, etc are being followed and are consistent with third party administrator responsibilities.
•Continuous innovation & development of the Wellness program to support the system and network needs with a focus on outcomes.
•Coordination with Beacon Health clinical leadership to develop, recommend, and implement wellness strategies throughout all risk populations.
•Creation of wellness programs that are flexible to meet scope and size of employers across the state of Maine.
•In collaboration with the Wellness Manager, development of business proposals in response to RFP's and/or inquiries.
Stop-Loss Payment and Reporting
•Responsible for managing of the stop loss strategy for Beacon Direct customers. In this role, the VP of BDS coordinates with carriers while incorporating claim protocols including specific trigger reporting claim levels and aggregate claim reporting.
•Coordinates large claim activity with carriers, sales and finance, while serving as the primary contact in the stop loss area. The VP of BDS represents the company during client and carrier directed claim audits.
•The Vice President of Beacon Direct Services is responsible for managing Beacon Direct's compliance requirements as they apply to the NLH Employee Health Plan and the fiduciary responsibilities of clients. The VP of BDS coordinates with system council, as well as inside and outside legal and compliance support as required, to support these activities.
•In collaboration with the senior management team, establishes and maintains procedural and financial auditing protocols. Also assuring that procedural criteria is established to maintain overall payment accuracy, while financial audits reflect payment accuracy and plan performance. The VP of BDS provides regular audit reporting to clients, management and actuarial support as required.
•Responsible for ensuring the claims vendor provides adequate training of claims, customer service and specialized support staff. Audit results are incorporated into the training program and redacted claims are offered to provide specific case studies.
•The Vice President of Beacon Direct Services participates in the selection and management of critical vendor relationships including PBM and predictive risk modeling software. The VP of BDS participates with senior management in the evaluation, selection and maintenance of PBM partnerships on behalf of the company and its clients. Additionally, the VP of BDS monitors PBM data to assure the smooth transition of information to the PBM and appropriate areas within the company
SKILLS AND ABILILITIES:
Demonstrated leadership in situations involving complex, large scale change. Skill and understanding of how to achieve results. Well-developed planning, marketing, organizational development and business skills. The ability to work with physicians, providers, staff and professionals in multiple settings and locations and promote diversity in the workplace. Information systems capabilities and appreciation for the data which will be required to make meaningful management decisions. Negotiation as well as financial analysis skills. Strong financial and business acumen, critical thinking, decision making abilities.
Strong communication skills, both verbal and written.
EDUCATION AND/OR EXPERIENCE:
Must possess a Bachelor's degree in business administration or related field from an accredited institution.
Master's degree in Business or Healthcare Administration strongly preferred.
At least 10 years' health plan operations or insurance industry experience required.
Managed Care experience a plus.
Proven experience resolving business operations issues or leading initiatives to improve processes or enhance systems experience preferred.
May require occasional evening and weekend work hours. Independent travel to sites throughout the system and surrounding communities is required. Must have valid drivers' license and reliable transportation. Must be willing to accept occasional overnight travel assignments
Flexibility, dexterity, visual acuity, hearing acuity. Able to work sitting at work station, using a keyboard, working in front of a video display monitor and answering the phone most of the day. Moderate walking throughout the facility. Light lifting of files and manuals, some bending to file.
Office environment, well-heated and well-ventilated. Ergonomically correct work station. Travel required.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.