Trust and Safety Leader
5 days ago
The AVP of Trust and Safety will drive CarePal Group's trust and safety strategy, overseeing hospital coordination, insurance claim processing, and TPA operations. This role demands a strong experience in setting and running processes in the healthcare insurance domain, including patient admission and discharge, billing verification, risk mitigation, and fraud prevention.
Main Responsibilities:- Hospital Coordination
- Manage relationships with hospital billing departments to ensure seamless service coordination.
- Oversee admission, discharge, and cost verification processes, ensuring adherence to CarePal's pricing agreements.
- Lead efforts to streamline billing accuracy, end-to-end claim processing, optimize reconciliation processes, and enhance the patient experience.
- Conduct cost verification and reconciliation with hospital billing & Finance teams to prevent discrepancies and ensure adherence to agreed rates.
- Develop structured reconciliation processes to accurately track and validate patient costs.
- Identify opportunities for cost-saving and process improvement in billing workflows.
- Oversee the full patient journey from admission through discharge, ensuring compliance with healthcare insurance guidelines.
- Coordinate with TPA and hospital teams for seamless admission, discharge, and insurance claim processes.
- Ensure all insurance-related processes are efficient, accurate, and meet regulatory standards.
- Manage patient background verification processes, ensuring accurate information validation.
- Implement standardized procedures for patient verification, proactively identifying and resolving discrepancies.
- Maintain high standards of trust and safety by ensuring complete and accurate patient onboarding till claim settlement.
- Lead TPA operations, focusing on claims processing, insurance documentation, and patient eligibility verification.
- Collaborate with TPA providers and insurance companies to ensure streamlined workflows and compliance.
- Enhance TPA operations by optimizing processes, reducing processing times, and improving patient satisfaction.
- Oversee insurance claim processes, implementing fraud detection and prevention strategies.
- Regularly monitor and audit for fraud risks, addressing any detected anomalies.
- Maintain high standards of trust by managing systems that prevent fraudulent activities in patient billing and insurance claims.
- Develop policies to uphold trust and safety in patient operations, aligning with healthcare and insurance standards.
- Regularly update policies to comply with regulatory changes and industry trends.
- Ensure strict adherence to data privacy laws, healthcare regulations, and insurance guidelines across all operations.
- Conduct risk assessments to identify potential issues, especially in hospital coordination, TPA processes, and patient verification.
- Lead escalation protocols to resolve trust and safety concerns promptly in collaboration with hospital and insurance partners.
- Regularly review processes to minimize risk and maintain high standards of operational integrity.
- Utilize data analytics to track operational trends, identify areas for improvement, and monitor patient satisfaction.
- Prepare regular reports on trust and safety metrics, incident outcomes, and fraud prevention results for executive leadership.
- Use data insights to refine processes, enhance efficiency, and guide strategic decision-making.
- Lead and mentor the Trust & Safety team, fostering a culture of accountability, integrity, and excellence.
- Ensure team members are well-trained in trust and safety protocols, billing verification, and insurance claims processes.
- Set clear objectives, conduct performance reviews, and support professional growth within the team.
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