The Director, Claims Operations is a highly functioning leader on the Health Plan Operations team. This position is responsible for healthcare claims strategy and operations, including managing vendors in support of the department. Development and execution of department efficiencies, compliance with all applicable state/federal regulations as well as service level agreements and performance guarantees, strategies to enhance the claims operations experience of our internal and external customers. Oversight of day-to-day claims operations including vendor management, claims processing, appeals management and benefit policy and product configuration. The Director works closely with other departments to execute on improving performance and efficiencies of claims operations.
What We're Looking For
Bachelor's degree in business or related healthcare field.
Five (5) years of experience in oversight of claims operations with expertise in both the public and commercial claims processing
Expertise in Medicaid and Medicare claims regulations and coding preferred
Supervisory experience required
Certified coder preferred but not required
Business process engineering experience preferred
5+ years of supervisory experience
5+ years of processing claims, preferably Medicaid and/or Medicare claims;
Experience in claims auditing/quality assurance role;
Solid understanding of CPT and ICD coding requirements. Coding certification preferred.
Knowledge of Third Party Liability and Fraud Waste and Abuse (FWA) issues.
Exceptional and proven successful leadership experience within a fast paced operations environment
Strong ability to translate and convey complex information into easy to understand, actionable recommendations
Excellent ability to function independently, set a strategic direction based on solid understanding of our goals and objectives.
Excellent project management skills; high critical thinking and analysis reporting experience
Excellent verbal, written and presentation experience communicating strategies and performance to the all levels of leadership
Highly skilled with Microsoft Office suite
Actual Work Location
2 Avenue de Lafayette, Boston, Massachusetts 02111-1750
Lafayette City Center
Exempt / Not Exempt
What You'll Be Doing
Develops and leads strategies for designing and improving robust claims operations platforms serving complex dually eligible Medicare and Medicaid populations;
Oversight of healthcare claims processing, ensuring accurate and timely payment to providers.
Represents Commonwealth Care Alliance in all client claims matters.
Leads strategies to enhance electronic transactions with internal and external customers and stakeholders.
Leads implementation of complex payment methodologies
Leads efforts of claims configuration to ensure claims rules are implemented and claims are processed accurately.
Accountable for claims processing and payment disbursement vendors management and oversight related to work deliverableand adherence to contractual obligations, statement of work and meeting/exceeding service level requirements
Ensures operational effectiveness of systems, processes, procedures and staffing levels for a high performing and evolving team.
Monitors claims approval rates and develops strategies to improve approval rates.
Ensures compliance with all client Service Level Agreements and Performance Guarantees.
Ensures compliance with all healthcare claims related contractual and regulatory requirements, including HIPAA, Mental Health Parity, prompt pay and all managed care laws.
Analysis of claim payments and denials to identify and address trends and opportunities for provider education and system improvements.
Serves as HIPAA compliant coding expert.
Manages all employees of the department and is responsible for the performance management and hiring of the employees within that department.
Works closely with the Vice President, Claims to identify trends, operational, initiatives, and areas of improvement and takes the necessary steps to implement the required changes.
Provides leadership direction in promoting positive relationships that cultivate associate engagement.
Works with other departments to promote integrated solutions to meet customer needs.
Participates in planning, development, implementation and evaluation of strategic business and performance goals, short and long term objectives, plans, budgets, programs and policies.
Continually look for process improvement opportunities; oversees and initiates process improvement projects.