Director - Claims Administration

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.
•    Develops and implements processes to ensure provider appeals/disputes are processed timely and in accordance with State and Federal regulations. Handles escalated claims issues and disputes, working to achieve resolution that is fair to the provider.
•    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.
•    Oversees the Claims system configuration and ensures all contracts, fee schedules, and benefits are set up appropriately for each line of business.
•    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, Compliance Committee, Total Quality Improvement workgroup, and System Set-Up team.
•    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 other duties as assigned.

Qualifications

EDUCATION        
•    Master’s degree required.

EXPERIENCE/ SKILLS    
•    Knowledge of HMO operations and medical claims adjudication.
•    Knowledge of medical coding
•    Extensive knowledge of state and federal HMO regulations (DHCS, DMHC, and CMS) 
•    Application level understanding of HIPPA, Privacy Act, and ERISA
•    Understanding of operations and the relationships between departments and functional areas.
•    Experience with QNXT 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.

Salary : $165,341 - $202,542