QUALIFICATIONS / REQUIREMENTS:
- Bachelor's degree in healthcare management, Business Administration, Finance, or related field
- Master's degree preferred
- 7+ years in healthcare claims management, financial control, or provider relations, including at least 2 years in a managerial or supervisory role
Key Activities:
- Oversee the design and implementation of Claims Management policies, procedures, and controls covering all areas of assigned Claims Management activity and provide continuous improvement recommendations.
- Ensure the development of the Claims Management strategic and operational plans, in alignment to CNHI's strategy, vision, mission, and corporate objectives.
- Direct the development of Claims Management objectives and goals by setting departmental objectives, managing performance, developing, and motivating employees to maximize functional performance.
- Ensure identifying the management needs of competencies and talents and provides recommendations with regards to human resources decisions.
- Ensure that all Claims Management reports are prepared timely and accurately and meet the requirements, policies, and quality standards.
- Delegate duties, responsibilities, and authorities to appropriate team members within the business in case of absence.
- Identify opportunities for continuous improvement of Claims Management and practices taking into consideration leading practices, efficiency and productivity improvement.
- Ensure compliance with all applicable laws, rules, regulations and standards within CNHI and related functions. Functional Responsibilities/Duties
- Oversee end-to-end claims management operations, ensuring timely and accurate processing, validation, and approval in line with benefit and contractual guidelines.
- Ensure the accuracy and integrity of submitted financial claims, verifying that all billed services were actually delivered and are supported by proper documentation.
- Develop and implement policies, controls, and review mechanisms to detect inconsistencies, errors, or fraudulent activities in collaboration with the Fraud, Waste, and Abuse (FWA) unit.
- Monitor claim processing performance indicators to identify bottlenecks, ensure timely resolution, and enhance process efficiency
- Analyze claim trends, financial data, and utilization patterns to identify abnormal behaviors, cost drivers, and improvement opportunities.
- Coordinate with healthcare providers and internal departments to resolve claim disputes, clarify documentation, and improve claims quality.
- Provide strategic insights and recommendations to enhance claims management efficiency, ensure compliance, and support sustainable healthcare spending.
