Description

POSITION SUMMARY

The Claims Director is responsible for the design, development, implementation, ongoing improvement and maintenance of claims handling systems, policies and procedures and for related provider services. Oversees all claims processing functions to assure timely, accurate and compliant claims processing.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Special Needs Plan (SNP).

RESPONSIBILITIES

• Ensures accurate and timely claims processing by monitoring and evaluating systems and operational policies and procedures; setting, measuring and monitoring quality and quantity standards for production; maintaining and analyzing accurate inventory processing systems to deploy appropriate resources; and taking appropriate corrective action as necessary with policies, processes and/or people.
• Produces inventory and production reports in user-friendly report formats and distributes appropriately for financial and organizational impact analysis.
• Interfaces with providers to provide instruction on billing procedures, resolving claims payment issues; coordinating in-service training with specialty and ancillary providers, and implementing sound provider recommendations for increased operational effectiveness.
• Integrates claims functions and responsibilities with other divisions as necessary, attending organizational and management meetings, and participating on committees such as the Service Quality Improvement Committee and NCQA Council.
• Develops and implements systems and structures to ensure management and staff competency and compliance with applicable policies, procedures, federal and state regulations.
• Adopts the QIP process within the division to identify and solve problems and issues, and includes all levels of staff in the process.
• Promotes a positive image of the organization and the department in all aspects of communication and contact.
• Performs related duties as required.

EDUCATION

• BS/BA degree in related field

EXPERIENCE/ SKILLS

• Knowledge of HMO operations and medical claims adjudication.
• Knowledge of medical coding
• Extensive knowledge of state and federal HMO regulations (Medicaid, CCS, DMHC and DHS)
• Application-level understanding of HIPPA, Privacy Act, and ERISA
• Understanding of operations and the relationships between departments and functional areas.
• Experience with Diamond 950 claims processing system preferred
• Knowledge of Medi-Cal claims processing, identification and processing of third-party and workers' compensation claims
• 2 3 years direct supervision of 5 or more professional or technical staff
• 5 7 years claims processing

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting.
• May be required to work evenings and/or weekends.
• Some traveling may be required.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action.

Qualifications