What are the responsibilities and job description for the Head of Claims Operations position at Wipro?
Role : Head of Claims Operations (Group Leader)
Summary :
The Head of Claims Operations and Service Delivery is tasked with shaping the overall strategy and enhancing the effectiveness of Claims Operations. This position is crucial for overseeing claims adjudication, regulatory reporting functions, and all associated processes. The Head ensures that claims processing is timely and accurate, manages relationships with vendors, and seeks out opportunities to improve operational efficiencies. Additionally, this role involves recruiting, training, and managing the performance of the Claims staff.
Education and Experience :
Bachelor's Degree in business, healthcare administration, or a related field (Master's preferred).
Minimum 7-10 years of experience in claims, healthcare administration, and / or managed care management.
Deep understanding of the health insurance industry across all product lines (Medicare, Medicaid, Commercial, ASO, DSNP, ACA, etc.).
In-depth knowledge of claims policies and procedures, including compliance with regulatory requirements and industry standards from AMA, CMS, and CCI edits.
Experience managing geographically dispersed (onshore and offshore), hybrid, remote, and onsite teams.
Experience in managing multinational operations is a plus.
Essential Duties and Responsibilities :
Strategic Leadership :
Provide clear strategic direction for the claims department, aligning its operations with company goals and regulatory requirements.
Lead, mentor, and cultivate a high-performing claims management team.
Collaborate with executive leadership to set and achieve claims-related KPIs and financial objectives.
Identify and implement effective solutions to address operational weaknesses.
Claims Management Operations :
Oversee the full spectrum of claims operations, including processing, adjudication, and resolution.
Devise and apply policies, procedures, and workflows that enhance efficiency and reduce errors.
Analyze claim denial trends and generate actionable insights to improve processes.
Maintain strong relationships with payers, vendors, and other key stakeholders.
Compliance and Reporting :
Guarantee compliance with state, federal, and industry regulations, including HIPAA and CMS guidelines.
Prepare and deliver regular reports on claims performance, trends, and departmental metrics.
Conduct audits and reviews to uphold standards of accuracy and regulatory compliance.
Team Development :
Lead and coach the Claims staff, nurturing a culture of accountability and continuous professional growth.
Develop staffing models to support the Claims budgeting process.
Establish a comprehensive Claims Quality program to assess both financial and clerical accuracy.
Operational Efficiency :
Leverage a thorough understanding of insurance processes and business systems to drive research and analytical efforts.
Develop and maintain departmental policies and procedures reflecting current business needs and regulatory requirements.
Monitor and evaluate system functionality and overall business performance.
Keep a pulse on the job market with advanced job matching technology.
If your compensation planning software is too rigid to deploy winning incentive strategies, it’s time to find an adaptable solution.
Compensation Planning
Enhance your organization's compensation strategy with salary data sets that HR and team managers can use to pay your staff right.
Surveys & Data Sets
What is the career path for a Head of Claims Operations?
Sign up to receive alerts about other jobs on the Head of Claims Operations career path by checking the boxes next to the positions that interest you.
