Healthcare Director, Claims Operations

posted on July 19, 2018

Job Description

Location: Columbus, OH

Type: Permanent

Job Summary:

In accordance with the Mission and Guiding Behaviors; the Director of Claims Operations and System Configuration directs the activities of all reporting positions in the Claims Operations and Claims System Configuration departments, including the delegated (vendor) relationships for claims processing to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achieve cost objective and service level goals; collaborate with all other Plan departments to assure Plan goals are achieved and compliance with Centers for Medicare and Medicaid Services (CMS) guidelines are met.

Job Qualifications (Knowledge, Skills, and Abilities):

  • Education: Bachelor’s degree required.
  • Licensure / Certification: CPC or equivalent preferred.
  • Experience: 8-10 years of Managed Care experience, preferably in Medicare Advantage.
  • 5 plus years of previous management experience in office environment analyzing and developing office/production systems/procedures.
  • Experience with Medicare and corresponding regulatory requirements preferred.
  • Effective Communication Skills.
  • 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.
  • Adequate computer skills including an understanding of the capabilities of basic software (word processing, online presentations, databases, spreadsheets).
  • Ability to provide strong leadership in a team environment.
  • Excellent written and verbal presentation and interpersonal communication skills.
  • Strong analytical, problem solving and organizational skills.
  • Ability to manage multiple priorities simultaneously.

Service Excellence:

  • Exhibits each of the Service Excellence Behavior Standards holding self and others accountable and role modeling excellence for all to see.
  • For example: demonstrates friendliness and courtesy, effective communication creates a professional environment and provides first class service.
  • Holds self and others (Associates, Physicians and Volunteers) accountable for exhibiting each of the Service Excellence Behavior Standards.
  • This includes, but is not limited to, celebrating excellence in behavior and approaching anyone with courtesy and respect who is not demonstrating Service Excellence and owning and resolving Service Recovery concerns.

Leadership Competencies:

  • Leadership Competencies are the required skills, knowledge and attributes of leaders.
  • They are principles that guide leaders toward the performance and accountabilities expected of them every day.
  • Define and share a strategy and vision.
  • Align resources toward achievement of UEM results.
  • Grow and sustain the UEM.
  • Identify, lead and embrace change.

Job and Technical Competencies:

  • 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.
  • Audit contract set-up and recommend changes based on results.
  • Audit Provider fee schedules and pay classes to ensure accuracy and correct payment.
  • 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.
  • Through auditing and internal reporting, proactively identify negative or positive trends and report to management with recommendations for change.
  • Assist in responses to Provider inquiries.
  • Participant on various committees as necessary and appropriate.
  • Maintain current industry knowledge as necessary and appropriate for position.
  • Oversight of the administration, configuration and ongoing maintenance of the claims adjudication system.
  • Directs the review of business process changes impacting the claims system.
  • Directs the implementation and continuous improvement of claims adjudication system management policies, standards and processes.
  • Establishes partnerships and works closely with the Senior Leadership Team to ensure claims system configuration accuracy; develop plans to address any potential system inaccuracies or configuration errors.
  • Leads compliance audits and remediates issues identified as required.
  • Meets population specific and all other competencies according to department requirements.
  • Promotes a Culture of Safety by adhering to policy, procedures and plans that are in place to prevent workplace injury, violence or adverse outcome to associates and patients.
  • Relationship-based Care: Creates a caring and healing environment that keeps the patient and family at the center of care throughout their experience following the principles of our interdisciplinary care delivery system.
  • (For nursing leadership) Models and promotes professionalism in nursing practice within the model of the ANCC Magnet Recognition Program®.

Other Job Responsibilities:

  • Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing.
  • All other duties as assigned.