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Dir, Aflac D&V Claims


Location: Tampa

Job Type: Full time


Salary Range: $80,000 - $185,000

Remote/Hybrid/On-Site: Hybrid

We’ve Got You Under Our Wing

We are the duck. We develop and empower our people, cultivate relationships, give back to our community, and celebrate every success along the way. We do it all…The Aflac Way.

Aflac, a Fortune 500 company, is an industry leader in voluntary insurance products that pay cash directly to policyholders and one of America's best-known brands. Aflac has been recognized as Fortune’s 50 Best Workplaces for Diversity and as one of World’s Most Ethical Companies by

Our business is about being there for people in need. So, ask yourself, are you the duck? If so, there’s a home, and a flourishing career for you at Aflac.

What does it take to be successful at Aflac?

  • Acting with Integrity
  • Communicating Effectively
  • Pursuing Self-Development
  • Serving Customers
  • Supporting Change
  • Supporting Organizational Goals
  • Working with Diverse Populations
  • Acting as a Champion for Change
  • Demonstrating Initiative
  • Developing Talent
  • Managing Performance

What will you be doing in this role?

  • Documented successful work experience demonstrating strong interpersonal skills
  • Demonstrated experience in benefit structures, Medical Advantage and PPO claims, payments, and regulations
  • Knowledgeable in medical terminology, procedure coding, electronic claims, coordination of benefits
  • Knowledge of processing systems and core claims and administration systems, as well as web-enabled and electronic data transfers.
  • Demonstrated strong, working understanding of Total Quality Management techniques

Education & Experience Required

  • Bachelor's Degree Business Administration or related field
  • Seven or more years of experience in managed healthcare administration including operations management, claims processing, billing, and utilization management

Or an equivalent combination of education and experience

Principal Duties & Responsibilities

  • Direct and oversee the daily operations of both the Claims department and the Utilization Management department to ensure accurate and prompt payments/auth decisions to providers meet or exceed internal/external SLAs, and are compliant with state or federal regulations
  • Develop appropriate Key Performance Indicators and reporting thereof to deliver insights for all responsible departments and processes
  • Identify opportunities to improve department processes, reduce costs, or suggest changes to plan design through reporting and data analysis
  • Bring a highly collaborative, business partner mentality, both externally and internally when coordinating processes or troubleshooting and resolving challenges, resulting in building a high level of trust and respect
  • Develop highly trained and engaged teams which deliver on company’s values and strengthens its culture and the company’s brand
  • Takes a central role in new client implementations, both commercial and Medicare Advantage to ensure departments are accountable for smooth integrations and providing an excellent customer experience
  • Create post implementation reporting scorecards to measure effectiveness of system configurations with respect to inaccurately paid claims
  • With PR, develop relationships with large DSOs and Optical Retailers to ensure these critical organizations rank Argus’ claims operations among their top payers
  • Collaborate with Finance regularly through effective and frequent communication on mutually agreed upon analysis to deliver insights on utilization and claims payments
  • Collaborate with Customer Service leadership to ensure Provider and Customer inquiries regarding claims status, benefit utilization, and grievance and appeal inquiries are answered accurately, timely, and in a manner that reflect excellent customer service and meet all agreed upon SLAs
  • Responsible for the maintenance of system of clinical rules and edits necessary to protect policy holders against improper billing practices
  • Develop and implement business plans assuring the delivery of cost-effective high quality medical and administrative services for Medicare and Medicaid members
  • Ensure revenue management and reconciliation systems that contribute to profitability and ensure compliance with governmental regulations
  • Perform other duties as required

Total Rewards

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions including, but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. The range has been created in good faith based on information known to Aflac at the time of the posting. Compensation decisions are dependent on the circumstances of each case. This salary range does not include any potential incentive pay or benefits, however, such information will be provided separately when appropriate. The salary range for this position is $80,000 to $185,000.

In addition to the base salary, we offer an array of benefits to meet your needs including medical, dental, and vision coverage, prescription drug coverage, health care flexible spending, dependent care flexible spending, Aflac supplemental policies (Accident, Cancer, Critical Illness and Hospital Indemnity offered at no costs to employee), 401(k) plans, annual bonuses, and an opportunity to purchase company stock. On an annual basis, you’ll also be offered 11 paid holidays, up to 20 days PTO to be used for any reason, and, if eligible, state mandated sick leave (Washington employees accrue 1 hour sick leave for every 40 hours worked) and other leaves of absence, if eligible, when needed to support your physical, financial, and emotional well-being. Aflac complies with all applicable leave laws, including, but not limited to sick and safe leave, and adoption and parental leave, in all states and localities.