Claims Director

Claims Director

Permanent job opportunity

Remote is workable but candidates need to be located in Santa Cruz, Monterey, Merced, Mariposa, or San Benito county in California

Salary: $190k + Company benefits

POSITION SUMMARY

Under policy direction, this position:

1. Provides strategic management oversight in implementing, directing and monitoring the Claims Department functions, including the development and implementation of new programs and services related to claims operations

2. Directs and oversees the Claims Department, acts as a subject matter expert, and provides direction and advice related to Claims Department functions and overall business operations

3. Directs, manages and supervises Claims Department staff

4. Performs other duties as assigned

RESPONSIBILITIES

1. Provides strategic management oversight in implementing, directing and monitoring the Claims Department functions, including the development and implementation of new programs and services related to claims, with duties including but not limited to:

Ensuring that the Claims Customer Service, Claims Operations and Claims Quality units function in an effective and responsive manner, in accordance with all applicable regulations

Overseeing and managing regulatory audits, deliverables and inquiries related to departmental services

Working with Claims Department managers to ensure effective monitoring and support and efficient and accurate performance of the claims processing operation

Acting as a resource to staff in the areas of claims processing and administration

Ensuring that the Claims Department provides quality service by enforcing claims quality and customer service standards, analyzing quality and customer service issues, identifying trends, recommending improvements, identifying new technology, and advancing operational effectiveness

Overseeing orientation and training of providers regarding the claims operations and resolving disputes and inquiries from providers, as needed

Achieving compliance by adhering to federal and state regulations, legislation and laws, auditing reports and system functions, comparing departmental functions with established standards, and making needed modifications

Advancing organizational objectives by aligning department actions, assessing departmental operations, engaging in continuous improvement efforts, making recommendations, and developing and implementing action plans

Leading tactical efforts and sponsoring projects through the management of cross-functional teams supporting existing or new business operations

Initiating enhancements to claims operations, identifying business needs and making recommendations on functionality of systems

Researching, proposing and implementing policy changes, identifying impact to business operations, and implementing new programs or services related to claims operations

2. Directs and oversees the Claims Department, acts as a subject matter expert, and provides direction and advice related to Claims Department functions and overall business operations, with duties including but not limited to:

Participating in the general administration as a member of the senior leadership team by providing input into the problem-solving and decision-making process

Participating in strategic planning and implementation of the Claims Department operational goals related to the growth and development of business operations

Ensuring that Claims Department goals and activities are in alignment with the strategic plan

Conducting complex research and analysis related to claims strategies

Assisting in formulating strategic plans and goal setting in support of programs

Modeling and promoting effective interdepartmental communication

Preparing narrative and statistical reports and making presentations

Developing performance measures related to strategic goals and new projects and presenting to staff and the Board of Commissioners, as directed by the Chief Operating Officer (COO)

Preparing reports for the Board of Commissioners package for review by the COO

Drafting, recommending, and implementing administrative policies, and processes and procedures related to Claims Department operations

Maintaining current knowledge of relevant Federal and State laws, policies and directives, and organizational policies and procedures

Monitoring legislative and legal changes related to functions and ensuring appropriate communication of same

Reviewing and assessing overall department functions, core work, goals and structure, developing and implementing short- and long-term planning to achieve strategic objectives, and completing an annual department assessment

Overseeing the preparation and maintenance of records, reports and related documents

Serving as representative on committees and advisory groups, and overseeing and coordinating committees, as assigned

Developing and managing the Claims Department operations and budget

Attending and participating in internal and external meetings related to business operations

Providing support to the COO on operational initiatives as assigned

3. Directs, manages and supervises Claims Department staff, with duties including but not limited to:

Functioning through subordinate Unit Managers, as applicable, exercises full supervision of costs, methods, and staffing

Participating in the hiring selection, and salary administration of Department employees

Ensuring that Claims Department staff maintains up-to-date knowledge, skills and abilities related to the administration of assigned responsibilities and functions

Identifying, overseeing and assisting with priorities, assignments and tasks and reviewing work products, as needed

Providing mentoring, coaching development and growth opportunities for staff and subordinate supervisors

Evaluating employee performance, providing feedback to staff, and counseling staff when performance issues arise

Overseeing staff in multiple office locations and/or telecommute settings

4. Performs other duties as assigned

EDUCATION AND EXPERIENCE

Bachelor s degree in Finance, Business Administration, or a related field and a minimum of ten years of claims operations experience in a managed care environment, which included some experience with financial management, a minimum of three years of experience working with Medicare and Medi-Cal Programs, and a minimum of five years of management-level experience (a Master s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

KNOWLEDGE, SKILLS, AND ABILITIES

Thorough knowledge of the principles and practices of claims operations and the claims function in a managed care environment

Thorough knowledge of and proficiency in research, analysis and reporting methods

Thorough knowledge of and proficiency in promoting and applying change management principles

Thorough knowledge of the California Medi-Cal program, Medicaid, Medicare, entitlement programs, and related regulations

Working knowledge of medical terminology, related procedures and diagnostic coding

Working knowledge of the methods and techniques of medical billing

Working knowledge of healthcare regulatory processes and regulatory and contractual compliance activities

Working knowledge of the principles and practices of provider dispute resolution

Working knowledge of the principles and practices of program development and project management

Working knowledge of the principles and practices of customer service

Working knowledge of the principles and practices of supervision and training

Working knowledge of and proficiency with Windows based PC systems and Microsoft Word, Excel, Outlook and PowerPoint

Ability to direct, manage, supervise, mentor, train and evaluate the work of staff

Ability to develop, plan, organize and direct programs and activities that are complex in nature and regional in scope

Ability to provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues

Ability to act as a technical resource and explain complex laws, regulations, processes, and programs related to area of responsibility

Ability to demonstrate strong analytical skills, accurately collect, manage and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk

Ability to analyze and interpret legal and contractual language

Ability to assess departmental operations, identify opportunities for improvement and advance operational effectiveness

Ability to identify and resolve problems in a timely manner

Ability to manage multiple projects simultaneously, organize work, and achieve goals and timelines

Ability to oversee the development and implementation of projects, systems, programs, policies, and procedures

Ability to foster effective working relationships, influence others and build consensus with individuals at all levels in the organization

Ability to demonstrate a collaborative management style, build rapport, and effectively manage internal and external business relationships

Ability to make presentations and adjust communication style in order to facilitate collaboration and understanding

Ability to prepare narrative and statistical written reports, oral reports, correspondence, and other program documents

Ability to develop and monitor department, program and project budgets

Ability to develop recordkeeping systems and maintain organized and accurate records

Ability to identify and develop new processes and systems to improve productivity and results

DESIRABLE QUALIFICATIONS

Master s degree in Finance, Business Administration or a related field