POSITION SUMMARY

Provides vision, leadership, and management of dental claims processing, customer service and quality assurance functions for HDS's commercial, Medicare, and Medicaid business. Is responsible for initiating and setting departmental goals and activities according to the strategic objectives of HDS, planning the activities and programs from start to completion involving deadlines, milestones, and processes, developing budget and operation, and ensuring these activities and programs are implemented in a manner that is compliant with applicable regulatory requirements. Directs the activities of the department, supervises staff, coordinates activities with other departments, and serves as the claims, customer service, and quality assurance expert for HDS, Med-Quest Division, health plans, DDPA, and others.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Effectiveness/Efficiencies– Develops, implements, evaluates and recommends best practices to ensure effective work processes and systems, maximize operating efficiencies and increase the value of services provided in alignment with department and company goals and objectives.
   • Develops and implements claims, customer service and quality assurance strategic plans.
   • Ensures timely and accurate processing and adjudication of HDS dental claims in accordance with processing policies, procedures, and other requirements.
   • Ensures customer service calls, inquiries, and appeals are answered and resolved within established standards.
   • Manages applicable performance guarantees.
   • Performs required reporting timely and accurately.
   • Directs internal research and reviews, determines appropriate action(s), and responds in a timely manner.
   • Coordinates and collaborates with the Information Technology and Systems (ITS) department concerning system development projects for the department. Ensures that system testing is complete, organized and documented and systems/applications can be successfully implemented.
   • Works with health plans, Med-Quest, auditors, HDS staff and others to resolve matters and satisfy various requests.
   • Is the SME in all claims, customer service and quality assurance matters.
2. Internal Controls/Compliance – Develops, implements, evaluates and recommends controls to satisfy operational/compliance risk requirements, ensure data integrity and best practices. Keeps abreast of current regulations and compliance issues that may impact the department and company.
   • Develops and maintains departmental performance measures and standards. Communicates and ensures that employees have a clear understanding of performance expectations and responsibilities. Provides direction to staff, as necessary. Continuously raises expectations and performance levels without sacrificing procedural and data integrity and quality.
   • Provides training for others on claims, customer service and quality assurance matters.
3. Management and Supervision
   • Supervisory 
     • Supervises/Manages the following staff: Direct Reports: 1 Customer Service Manager; 1 Claims Manager; and 1 Quality Assurance Manager. Manages, plans, organizes, supervises, trains, motivates and evaluates staff; including making final hiring & termination decisions, assigning work, developing growth opportunities, conducting performance evaluations and taking corrective action. Communicates and assures that employees have a clear understanding of performance expectations and responsibilities. Plans, directs and manages toward effective and appropriate activities and ensures satisfactory performance of those employees.
   • Budget
     • Develops and manages department's annual budget in alignment with company goals and objectives. 
   • Business Plan/Establish Departmental Goals
     • Develops and implements claims, customer service, and quality assurance operational plans, including best practice strategies and solutions to address current and future competition and business trends.
     • Contributes to executive's development of company goals, incentives, and standards and monitors and reports on these goals, incentives, and standards. 
   • Policies/Procedures
     • Develops and implements departmental policies and procedures that comply with applicable regulatory requirements.
     • Works with various stakeholders to respond to their inquiries regarding claims, customer service and quality assurance activities, policies, and procedures.
4. Other Duties and Responsibilities
   • Customer Service (Internal/External)
     • Plans, directs and manages the activities related to the department. Monitors productivity and performance while ensuring professionalism, quality, timeliness and accuracy in accordance with overall company-wide objectives to ensure positive working relationships with internal and external customers.
     • Collaborates with other Delta Dental member companies on operational issues.
     • Works with other department managers on project teams for proposals, implementations and other corporate projects. 
   • Performs other related duties as required or assigned by the Chief Operating Officer.
   • May perform routine administrative tasks as needed.

MINIMUM QUALIFICATIONS AND EXPERIENCE

Education

• Bachelor’s degree in Business Administration or Public Health Administration or equivalent required. 
• Master’s degree in the above is preferred.

Experience

• Minimum of 5 years management experience, preferably in operations for a health or dental insurance company.
• Minimum of 2 years of experience managing of staff.

Skills and Knowledge

• Ability to analyze complex topics or issues and effectively resolve the problems.
• Ability to handle multiple tasks and prioritize with some distractions and attention to details and produce expected outcomes.
• Ability to handle information in a confidential manner and maintain compliance with HDS policies and federal/state laws.
• Technical knowledge to understand computer applications for claims processing and call center operations as well as business problem-solving (prefer Windows, Word, Excel, and PowerPoint).
• Duties require use of considerable initiative, leadership skills, creativity, judgment, problem-solving, and working under minimal or no supervision. 
• Requires working under frequent deadlines and pressure; dealing with difficult people and situations involving complex issues; and negotiating, establishing and maintaining cooperative and productive business and work relationships.
• Requires communicating effectively both orally and in writing; giving instructions or directives to others, all levels of staff, customers, vendors and others on sensitive matters; and seeking information from a variety of sources.

Note: The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job. Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform the essential functions of this position.