Director of TPA Miami, FL

Position Summary

The Director of TPA Operations will be responsible for leading and overseeing all functions within the Claims, Revenue Cycle Management, Auditing, Customer Service, and Data Integrity departments. This role will involve close collaboration with the VP of TPA Operations and department heads to ensure the efficient processing and management of TPA operations for providers, while ensuring full compliance with federal and state regulations.

Duties and Responsibilities
Oversight of TPA Departments and Department Heads

• Oversee claims processing functions of the TPA, health plan, and federal regulations and reporting.
• Responsible in developing and efficiently managing the daily operations for operation departments Medicare, Medicaid, and Commercial/ Plans.
• Ensure a motivated culture by developing motivational programs to increase team loyalty and to create an atmosphere of fun in the Departments.
• Lead daily huddles and bi-weekly meetings with Supervisors and Managers to ensure alignment, address challenges, and drive departmental goals.
• Conduct monthly staff meetings for the department to ensure effective communication and collaboration
• Covers TPA departments supervisors and managers when necessary to perform pre-payment audit and payment cycle.
• Develop strategies, goals and objectives for each department.
• Develop management and analytical skills of Management on a one-on-one basis
• Supervise and train all managers/supervisors of all departments, and oversight of all the department's functions and growth.
• Effectively and efficiently operate the TPA’s operation departments on a consistent basis

Claims

• Implement and oversee Medicare/Medicaid changes (i.e., changes of CPTs/DXs, Local Coverage Claims Processing Guidelines).
• Work in conjunction with the VP of TPA Operations to research, review and interpret Policy and Network Guidelines.
• Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims and encounter processing and provider inquiries (written or verbal).
• Collaboration and communication with other departments on claims and encounter issues, related projects, and inter-departmental operations issues.
• Maintain a full comprehensive understanding of the covered benefits, coding and reimbursement policies and contracts.
• Participate and fully cooperate in the health plan's accreditation efforts and annual audits.
• Analyze, track and trend of all departments and transaction data; identify any potential service or systems issues; implement interventions and determine success of intervention.
• Completes performance objectives, performance reviews, salary changes, and disciplinary actions on a timely basis as per Company policy. Conduct interviews for new position with Supervisor/Manager.

Data Integrity

• Attend and present TPA data to all health plan JOCs.
• Performs other duties as required and assigned.

Knowledge/Experience

• Bachelor’s Degree or equivalent experience
• 5-8 years of Claims Management experience in the healthcare organization.
• Must have Health Maintenance Organization experience (HMO, PPO, etc.)
• Benefit Configuration
• Provider Contract Load
• Proven experience in managing a diverse workforce across various roles and backgrounds.
• Broad medical terminology, CMS and AHCA regulations and reporting
• Experience in healthcare data management
• Extensive knowledge in regulatory compliance for claims processing.

Skills

• Demonstrated experience developing and leading process improvement projects that drove operations efficiencies.
• An entrepreneurial mindset geared toward creating, executing, and continuously improving health plan operations and implementations.
• Provide coaching and collaborate with Supervisors and Managers to identify process gaps and opportunities for improvement, including recommending necessary system enhancements.
• Lead the development of strategies to effectively communicate and implement process improvements across all departments.

Abilities

• A wide degree of creativity and latitude is expected.
• Rely on experience and judgment to plan and accomplish goals.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00
p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 10% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Job Type: Full-time

Pay: $100,000.00 - $120,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off

Schedule:

• Monday to Friday

Work Location: In person

Salary : $100,000 - $120,000