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Process Improvement Manager

SUMMARY

Under the direction and in support of the Director of Process Improvement, the Process Improvement Manager will be responsible for identifying areas for operational improvement, engage and organize cross-departmental stakeholders, implement changes, ensure testing efforts, and monitor process performance.  Recommends and implements initiatives to improve department efficiency, productivity, workflows, and enhance member and provider experience.  Also translates business needs into functional specifications.

 

ESSENTIAL FUNCTIONS

Critical features of this position are listed below and may be revised, updated or reassigned at management’s discretion in accordance with business needs or other factors.

  • Lead and support continuous process/system enhancements and contribute to cross-functional workflow development.
  • Oversee and support the execution of identified process improvement opportunities by working closely with cross-functional teams, including but not limited to IT, Service, Clinical, PMO, Client Success, Finance, Specialty Services, Claims, and Analytics.
  • Develop a sustainable lean philosophy that focuses on bringing value to WIN patients and enhancing member and provider experience.
  • Gather and document business specifications.
  • Assists in short-term and long-term prioritization of WIN initiatives.
  • Maintain thorough documentation of process changes and requirements and communicates regular updates to WIN Leadership.
  • Facilitate brainstorming and team collaboration for problem-solving.
  • Work directly with IT and other related departments on system enhancements and automation initiatives.
  • Establish best practices, standardize, and support new client implementations.
  • Support internal customer service and claims workflow audits.
  • Reviews completed complex customer issues escalated by team members and performs post-mortem analysis to identify and effectuate process improvements.
  • Communicates operational changes and supports training efforts.

 

SUPERVISORY RESPONSIBILITIES

None

 

MINIMUM QUALIFICATIONS

  • Bachelor’s degree in a business-related subject or equivalent experience. Master’s degree preferred.
  • Strong performance management and productivity optimization skills, including reporting, analysis and recommendations.
  • Strong technology background interfacing with IT personnel. MS Office and database knowledge required.
  • Working knowledge of current commercial health insurance product options, including HMO, PPO, EPO, high deductible plans, copay/coinsurance variations, and HRA’s/HSA’s.
  • Working knowledge of electronic commerce, including EDI submission and payment of provider claims, EDI submission to payers, EFT, transmission of forms, and web portal interface for providers and members.
  • Knowledge of medical coding, including ICD-10, NDC/GPI, CPT/HCPCS.
  • Thorough HIPAA knowledge.

 

KNOWLEDGE, SKILLS AND ABILITIES

  • Analytics, Six Sigma process improvement, database experience.
  • Advanced knowledge and experience with Excel, Project and spec software development tools.
  • Knowledge of NCQA Guidelines, URAC Accreditation and Utilization Management desirable.
  • Experience with pharmacy benefit management, disease management, care management or the pharmaceutical industry desirable.
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