We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.
The Senior Director of Claims is responsible for management and oversight of claims processing, provider dispute resolution processes, along with auditing programs. The position will drive strategic planning, operational excellence and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial, Exchange and Medicaid service lines. The incumbent sets strategy for the claims business units and is responsible for integrating the various components of the business to ensure operational and developmental goals are achieved.
Ensure Claims are adjudicated timely and accurately to assure conformity with internal, health plan and regulatory guidelines and requirements
Create, monitor and manage metrics and goals to ensure compliance with regulatory guidelines and maximize cost effectiveness for the department and external vendors
Oversee and manage claims processes performed by delegated vendors including but not limited to the TPA and other vendors for which any claim related function is outsourced.
Manage the relationship with the TPA/BPO for claims processing using defined metrics and goals, including providing timely performance evaluations and implementing corrective action when necessary
Develop and implement operational strategy to reduce claims inventory, increase auto adjudication rate, improve quality, reduce cost of a claim and maximize claims compliance efforts
Collaborate with other departments such as UM, CM, Pharmacy, Eligibility, Performance Programs, Compliance, Configuration, Network Management IT Ops to drive operational excellence, including but limited to identification and implementation of Auto-adjudication rules, claims pend rules, claims editing rules and authorization rules
Ensure Provider Disputes and Provider inquires/calls are resolved timely and accurately to assure conformity with internal, health plan and regulatory guidelines and requirements
Create, monitor and manage metrics and goals to ensure compliance with regulatory guidelines and maximize cost effectiveness to achieve operational efficiency
Ensure PDR/Provider Inquiry trends are monitored proactively, researched for root cause to devise a prevention plan
Drive and oversee the Internal and External Claims Audit Strategy for the organization including Claims testing Strategy
Ensure clear metrics are defined, measured and reported for tracking and trending Claims audit and testing outcomes
Ensure corrective action plan (CAP) management for issues identified as part of all audits performed with clear root cause analysis and prevention plan
Ensure all HP reports (scheduled and ad-hoc) are pulled timely and reviewed for accuracy
Documentation, Training & Development
Drive and ensure internal process adherence for creating/ maintaining cross functional/departmental claims processes, workflows, policies and procedures, job aides and standard operating procedures
Ensure adherence to all Legislative, Regulatory and Contractual requirements
Drive and oversee the Training Plan & Training Strategy for the Claims department including measuring training effectiveness and remediation strategy
Drive and collaborate with IT & Data Analytics team to create/ develop tools to effectively maintain, update, or revise all scorecards, dashboards, and reports, as necessary
Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution
Act as a consultant for senior management from other departments for, but not limited to claims processing protocols, guidelines and industry trends.
Recommend changes for system design, rules, and workflows affecting the assigned departments
Conduct special projects including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing business and organizational requirements
Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements
Develop goals and objectives for the department and rollout strategy to obtain the established business outcome
Oversee monitoring and tracking of key performance metrics against established goals and coach/ guide the management team to achieve success
Recruit, develop, motivate and lead the Claims Department to continuously improve operational performance
Minimum Education: Bachelor's degree or equivalent experience preferred with healthcare administration focus required.
Minimum Experience: Ten plus (10+) years of experience in the healthcare industry required. Six to eight (6-8) years claims administration experience in a Health Plan/IPA/MSO setting required. Five plus (5+) years of experience in managing claims function in a large (50-100 employees) managed care environment required. Proven success in improving key performance metrics, including process improvement, cost reduction and improving efficiency. Demonstrated leadership skills, ability to coach, mentor and foster a culture of achievement. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines. IDX experience, Cotiviti Experience, Burgess Experience preferred. Worked with Clearinghouses like Office Ally preferred. Experience with Claims Imaging Vendors preferred. Experience with managing Mailroom processes preferred. Worked with offshore Vendors preferred. Core System implementation experience preferred. Core System configuration experience preferred.
Req. Certification/Licensure: None.
Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:
Medical, dental, vision insurance
Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.
How to Apply
To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.