- Provide operational leadership and guidance to Health Fund staff and cross-functional stakeholders; support staff training, workflow oversight, and implementation of operational best practices
| - Lead cross-functional operational workgroups involving Health Services, Member Services, Eligibility, Compliance, Legal, Finance, Information Technology, Analytics, and external vendors; build consensus, facilitate decision-making, and drive accountability for operational initiatives and project deliverables
| - Prepare recurring operational reports and executive-level summaries that identify performance trends, unresolved risks, corrective actions, and recommended next steps, and present findings and recommendations to Health Fund leadership as appropriate
| - Serve as subject matter expert and manage plan design, medical benefits, cost share information, and take principal responsibility for the following:
- Monitor and evaluate operational performance, service levels, productivity, quality assurance results, and claims-related metrics; identify trends, recommend operational improvements, and implement corrective actions in partnership with the Assistant Director. Serve as a resource to leadership regarding operational risks, opportunities, and service delivery performance.
- Manage day-to-day operational relationships with the Fund’s third-party administrators, provider networks, and other health vendors, including monitoring operational performance, tracking performance guarantees, key performance indicators, service-level agreements, open issues, and corrective-action commitments, and escalating significant operational concerns to Health Fund leadership
- Ensure Health Fund staff, Member Service Representatives, and external shareholders all maintain a shared understanding about the covered benefits with regard to what benefits are covered, how claims are processed, and what limitations apply to covered benefits
- Review and revise plan documents (including Summary Plan Descriptions, Summary of Benefits and Coverage) as needed
- Understand and operationally apply the rules of health plan design in order to resolve plan participant related matters
- Partner internally and with the Fund’s Third-Party Administrator (TPA) to track, document and maintain updates and changes to the Fund’s medical plan designs
- Work with Health Fund staff to monitor inquiries and complaints resulting from systemic problems, such as miscoding of benefit categories or improper implementation of benefits to follow Health Fund’s plan documents
- Lead the investigation and resolution of escalated member, provider, benefit, and claims-administration issues, coordinating with vendors and internal departments and escalating material risks
- Monitor operational compliance with the Summary Plan Descriptions, Summary of Material Modifications, benefit summaries, Fund policies, contractual requirements, HIPAA requirements, and applicable service standards
- Develop and maintain quality-control processes to identify benefit configuration, claims-processing, documentation, and service-delivery errors; establish corrective-action plans and monitor them through completion
| - Develop, maintain, and enhance the Health Fund portions of the 32BJ Benefit Funds member portal and the internal CRM
- Meet with enterprise stakeholders and end users to identify, prioritize, understand and document business and technical processes and requirements
- Facilitate process workflow modeling in order to collaborate on process improvements, automation capabilities and clearly defined end-to-end use cases
- Develop process documentation/workflows outlining current state and future state, knowledge articles and self-service guidance
- Provide ongoing portal and CRM training to Health Services staff
- Track major incident management process and ensure adherence of the process and escalation requirements within the various support and delivery areas
- Coordinate operational readiness for benefit changes, plan-design updates, vendor implementations, system enhancements, and regulatory or organizational initiatives, including testing, documentation, communications, training, and post-implementation monitoring
- Coordinate user-acceptance testing and validate vendor benefit configurations and system changes against approved plan provisions and business requirements
- Develop, maintain, and periodically review operational policies, standard operating procedures, workflows, escalation protocols, knowledge articles, and other documentation supporting Health Fund Operations
- Identify issues and risks, and maintain trackers for issues, risks, decisions, and implementation items and perform root-cause analysis of recurring complaints, processing defects, and operational incidents
- Recommend process automation, workflow redesign, and system improvements that improve accuracy, efficiency, and the member experience
| - Identify, develop, and lead engagement opportunities for plan participants
- Analyze claims data and operational data to identify member education campaigns
- Implement campaigns into call center scripting, CRM functionality and portal functionality
- Advise and provide additional support to the Health Operations team
| - Support audits, compliance reviews, and responses to operational document and data requests
- Support vendor evaluations, implementation planning, contract-performance reviews, and follow-up on operational commitments arising from Request for Proposal initiatives
| - Provide functional leadership to project teams, operational stakeholders and serve as a designated backup to the Assistant Director, Health Operations, ensuring continuity of operations, stakeholder coordination, and issue resolution
| - Perform other relevant duties as assigned by management and senior leadership
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