Job Details

The TPL Manager is responsible for leading a highly skilled team in the identification, coordination, and recovery of medical claims expenses from third-party resources. This role ensures compliance with regulatory and contractual requirements, optimizes reimbursement opportunities, and continuously improves operational efficiency. The TPL Manager is directly accountable of staff for the intake, analysis, and reconciliation of third-party resource files and claim reviews to exceed service performance objectives.

Job Description

• Leads and manages the TPL staff, providing guidance, goal setting, support, and professional development as well as performance monitoring and strategic planning.
• Evaluates unit activity reports and reviews staff production for completeness, accuracy and timeliness of claim research and resolution; and assures the timely updating of data into the automated files and systems.
• Consolidates validated TPL financial value data from various sources to enable reporting, trend analysis, benchmarking, and forecasting in support of strategic decisions and key performance indicators.
• Maintains accurate up-to-date third party liability files and data on eligible membership recipients for entry into computerized system
• Establishes measures to identify and verify third party resources to support cost-avoidance and recovery of funds not the responsibility of JHP., i.e. TPL Flagging
• Ensures the timely and effective handling of claims in accordance with service level agreement requirements.
• Develops, implements, and maintains new policies and procedures related to TPL and associated operational processes as needed.
• Implement best practices and innovative solutions to enhance TPL programs.
• Stays informed about best practices and emerging trends through engagement with external partners such as auditors, regulatory agencies, and industry groups.
• Maintain and foster a collaborative relationship with internal and external customers.
• Communicates with Leadership regarding departmental quality improvement initiatives, issues which involve coverage and/or payment policies and provider complaints of significant importance to warrant intervention to correct problems or a change in claim processing procedures.
• Analyze standard generated reports and develops ad hoc reports, as needed, to take appropriate actions to reduce errors, suspended or otherwise inappropriately handled claims.
• Identifies recovery initiatives through data analysis of TPL data, claims payments,  and other payment resource investigation
• Collaborate with Legal, Claims, IT, and external vendors to streamline TPL processes and recovery efforts.
• Perform other duties as assigned.

Key Job Requirements:

Education:       Bachelor’s Degree required or 5-7 years experience in managed care and/or indemnity insurance with a minimum of 3 years in a management position.

Skills/Abilities: Previous claims management experience preferred.  Experience in claims processing and regulations.  Excellent organizational, interpersonal, time management and communications skills.  Strong conflict resolution skills.  Process and project management ability.

Compliance Statement:  Compliance with all applicable rules, regulations and laws is a condition of employment.  Employees must read and sign the Code of Conduct and be expected to perform their duties ethically and honestly.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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