Director, Claims (Commercial-Self-Funded)

The Director of ASO and HMO claims is responsible for the management of the ASO and HMO products administered by The Health Plan. The Director assists the staff with education, communication, and problem solving. The director works closely with the Vice President of Operations. The Director manages daily operations of multiple levels of staff. Manages claims inventory with claims and stop loss managers to ensure productivity for analyst is at accepted levels. A Provides leadership both internally and externally.

Required:

1. Bachelor’s Degree or equivalent experience.
2. Experience in healthcare insurance operations.
3. At least 5 years of previous claims leadership/management experience.
4. Experience with medical claims payment, ICD-10, NDC, HCPCS.
5. Strong analytical skills, including excell worksheets/formulas.
6. Clear, concise verbal/written communication skills.
7. Experience leading, formulating and delivering strategy, building strong connections with internal and external clients, customers, departments and teams.

Desired:

1. Demonstrates integrity and ethical standards.
2. Accountable with ability to deliver on commitments and take ownership for solving problems and creating solutions.
3. Strong, positive leadership skills.
4. Desire for continuous improvement and innovation with the ability to embrace change and drive new ideas into business solutions.
5. Experience with Project Management.
6. Stop Loss Reporting & Tracking Experience.

Responsibilities:

1. Directs all aspects of institutional and professional claims review for medical appropriateness and compliance with prompt pay regulations.
2. Assists with the development, implementation, and updates to claims review procedures/criteria, physician and ancillary fee schedules and hospital contractual rates.
3. Monitors check runs and monthly reports to detect potential problems or issues.
4. Coordinates claim review activities with internal departments as well as participants on internal committees representing the claims department and formulates workflow between all departments.
5. Responsible for interviewing and hiring of all staff and conducts annual employee performance reviews for direct reports.
6. Monitors all daily activities with the assistance direct reports regarding claims processing/review, productivity, timeliness of payments and quality indicators of services.
7. Conducts second reviews for Self Funded claims.
8. Monitors and distributes reports as necessary.