Healthcare Director – Claims

posted on August 30, 2018

Job Description

Location: New York, NY

Type: Permanent


  • The purpose of this position is to assure timely and accurate processing of claims and encounters in accordance with the NYS Prompt Payment Law as well as responding to provider telephone calls, written inquiries, and appeals regarding claims and encounters.
  • This includes continuous accurate administrative data management, ongoing quality reviews and coordination of the activities for the Claims Cost Savings Program.

Goals and Essential Functions:

  • Establish departmental goals and objectives that are consistent with, and lead to the successful achievement of, divisional and corporate goals and objectives.
  • Achieve departmental goals and objectives by providing effective leadership, management, strategic direction, and budget and business planning.
  • Direct the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims processing and provider inquiries (written or verbal).
  • Compilation of all information and documents required for claims processing and related inquiries to assure compliance with all applicable rules, regulations, and external and internal policies and procedures
  • Review provider contracts and configuration of these contracts within the claims processing system to assure accurate payments to our providers
  • Collaboration and communication with other departments on claims issues, related projects and operational issues, in order to achieve Claims Department and the Office of the CFO goals
  • Development and maintenance of well defined processes to enter, adjust, manage and report claims data
  • Preparation and timely submission of management and regulatory reports derived from the claims database
  • Generation of configuration requests to enhance the claims department processes to assure accurate, timely administration of providers claim
  • Communication to all departments and personnel regarding claims information needed to perform their duties; and documentation of all departmental policies and procedures, following corporate standards.
  • Continually assess the effectiveness of departmental functioning, including the people, processes and technologies needed to achieve departmental and corporate goals and objectives.
  • Identify problems and opportunities for improvement, and generate creative solutions that improve qualitative and quantitative performance.
  • Recruit, hire, train, develop, motivate, manage, and lead staff to perform successfully.
  • Represent the company to external organizations, including but not limited to, government agencies, trade associations, providers and vendors in a manner that maintains the integrity and enhances the reputation of the company.
  • Assure compliance with all applicable contractual and regulatory requirements, including timely preparation and submission of reports, plans, corrective actions and related materials required by oversight agencies.
  • Assure successful implementation of corrective action plans.


  • Minimum of a BA/BS degree with at least eight (8) years of relevant professional experience.
  • Knowledge of the AMISYS system strongly preferred.
  • Minimum of five (5) years of health care administration and/or managed care experience.
  • Minimum of five (5) years of managerial experience at the department director or manager level.
  • Minimum of five (5) years of claims experience that demonstrates progressive growth within claims operations.
  • Extensive knowledge of claims policies and procedures, including industry standards from CMS and CCI Edits.
  • Thorough knowledge of business management principles and practices, and organizational policies and procedures.
  • Excellent oral and writing skills characterized by the ability to communicate thoroughly and clearly to a range of reading and comprehension skill levels.
  • Highly developed quantitative and qualitative analytical skills required to understand business processes and functions, compile and interpret appropriate data, and identify and solve problems.
  • Highly developed project management skills required to identify business and process needs, and integrate complex functions and/or highly diverse components of operational units.
  • Demonstrated ability to articulate goals, plan and implement processes to achieve those goals, recognize and assess the implications of confounding variables, anticipate consequences, and meet deadlines.
  • Advanced interpersonal (e.g., mediating, counseling, mentoring), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex.
  • Extensive experience in evaluating, developing, and implementing operating procedures and systems affecting the business environment, with the decision making authority to make changes.
  • Demonstrated ability to work resourcefully and creatively, to think independently, and to exercise independent judgement in originating or developing complex techniques or programs in a complex and dynamic environment.
  • High level of integrity as demonstrated by 1) appropriate treatment of confidential information, 2) adherence to policies, procedures, rules and regulations, 3) professional conduct in dealing with persons internal and external to the organization, and 4) sensitivity to target populations.


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