**Rating/Claims System Senior Advisor** **Location:** This position will work a hybrid model (remote and office). The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations in **Columbus, OH; Mason, OH; Indianapolis, IN; Chicago, IL; Manchester, NH; Boston, MA.** The **Rating/Claims System Senior Advisor** leads the activities for India based Commercial Claims Operations, Claims System Configuration, and Provider Data Management departments to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achievement of cost objectives and service level goals; provider data management and related downstream processes; collaboration with all other client departments to ensure client goals are achieved and compliance with guidelines are met. **How you will make an impact:** + Establish standards of performance, including training, policies and procedures, claims auditing and other performance measurement techniques. + Oversee all activities related to claims processing. + Primary oversight and responsibility for delegated claims functions performed by third party vendor, including claims processing and fulfillment. + Oversee the coordination of procedures for administering the various benefit plans and provider contracts with all interfacing systems. + Responsible for implementing and auditing benefit changes as related to claims processing. + Responsible for monitoring Medicare changes as they relate to claims payment and methodologies, benefits and coding and billing. + Develop and implement cost control measures. + Responsible for directing the processing and payment of claims. + Provides guidance on the most complex claims. + Develops short/long-term objectives and continually monitors procedures to ensure these are met by staff. + Stays abreast of state/federal regulations. + Manages commercial claims processing team located in CGS’s India site. + Works with business owners to identify and analyze requirements and processes with Information Technology and the vendor to ensure quality and timeliness of systems/project deliverables. + Position requires significant and regular external contact with customers or regulatory agencies. + Has significant budget accountability and manages special projects. + Translates the most highly complex and varied business needs into application software functionality. + These needs typically involve a significant expenditure or cost savings and impact a wide range of functions. + Configures new designs/updates in the system. + Monitors system and business functionality and performance. + Documents and tracks product defects. + Coordinates problem resolution with development and/or product vendors. + May implement rates, rating formulas, product and benefit configuration/information and as directed by the appropriate business unit. + Analyzes, develops and validates data. + Researches, documents and completes very diverse and complex projects and work processes to ensure business continuity and consistency. + Formulates and defines system scope and objectives based on user-defined requirements. + Supports and maintains the systems post-implementation. + Provides end user support, consultation, liaison communications, helpdesk triage, training, reporting, auditing, application security, and ad hoc inquiries and requests. + Provides expertise to lower level analysts. **Minimum Requirements:** Requires an BA/BS degree in Information Technology, Computer Science or related field of study and a minimum of 8 years systems analyst or business analyst experience; or any combination of education and experience, which would provide an equivalent background. **Preferred Skills, Capabilities, and Experiences:** + 8-10 years of leadership and Managed Care experience, preferably in Medicare Advantage strongly preferred. + Experience working closely with offshore IT support team strongly preferred. + Experience with Medicare and corresponding regulatory requirements preferred. + Comprehensive knowledge of the health insurance industry, including, but not limited to: claim adjudication procedures; insurance law; benefit design; plan document provisions and compliance regulation strongly preferred. + Excellent analytical ability, written, oral and interpersonal communication skills, negotiation skills, PC skills, advanced strategic planning, organizational, managerial and leadership skills strongly preferred.