What are the responsibilities and job description for the Director, Claims Eligibility position at Continental General?
Looking to join a growing company dedicated to helping others? We offer that, plus competitive salaries, a culture of learning, and a fast-paced environment. This is a hybrid position with 3 days in-office. We are also open to considering remote candidates. Join our team to help make a difference in the lives of others!
The Director of Claims Eligibility is a critical leadership role within the Claims Division, responsible for overseeing the operations and strategic direction of the long-term care claims eligibility team. This role ensures the delivery of exceptional service while maintaining compliance with company policies, industry regulations, and client expectations. The Director will manage a team of claims professionals, providing guidance on complex cases, fostering team development, and driving operational efficiency to achieve business goals.
Key Responsibilities:
1. Department Leadership:
Lead and manage the activities and services of the Long-Term Care Claims Eligibility team, ensuring efficient administration and adherence to company standards.
Serve as a key liaison between the department, corporate claims leadership, and external stakeholders to align departmental objectives with organizational goals.
Provide tactical leadership and strategic direction to support team success and continuous improvement.
2. Claims Oversight:
Review and provide guidance on complex or high-risk claims, ensuring consistent and compliant decision-making.
Oversee resolution of claim files, including attending arbitrations, mediations, depositions, or trials as needed.
Establish reserves and recommend settlements, working within established authority limits and escalating cases exceeding personal authority.
Ensure claims handling aligns with all applicable statutes, regulations, client expectations, and standard operating procedures (SOPs).
3. Operational Management:
Coordinate and monitor work activities, ensuring the team meets defined service-level agreements (SLAs).
Maintain up-to-date reports and metrics to track team performance, identifying areas for improvement and implementing solutions.
Plan and manage departmental budgets, ensuring resources align with business targets and objectives.
4. Team Development and Performance Management:
Provide coaching, mentoring, and professional development opportunities to team members, fostering a culture of excellence.
Lead the hiring, onboarding, and performance management processes to ensure the team operates at a high standard.
Develop and implement training programs to maintain compliance and enhance team expertise in claims handling.
5. Collaboration and Communication:
Work closely with senior leadership to develop strategies, address challenges, and implement organizational initiatives.
Communicate effectively with internal and external stakeholders, providing insights, updates, and recommendations.
6. Compliance and Quality Assurance:
Conduct regular reviews of claims to ensure consistency and compliance with regulatory requirements and company policies.
Maintain a strong understanding of legal and regulatory changes in the industry, adapting departmental practices as needed.
7. Other Duties:
Perform additional responsibilities as assigned by senior leadership.
Note: Applicants must be authorized to work for a U.S. employer without sponsorship. We are unable to sponsor or take over sponsorship of an Employment Visa at this time or at any time in the future.
Education:
Bachelors degree in Nursing, Social Work, or a related healthcare discipline (or equivalent work experience).
Advanced degrees, certifications, or licensures (e.g., RN, LPN, LCSW, MSW, MSN) are highly desirable.
Experience:
10 years of relevant experience in claims, insurance, or healthcare, with a minimum of 4 years in a supervisory or managerial role.
Background in long-term care, healthcare administration, or related fields is strongly preferred.
Skills and Competencies:
Strong knowledge of long-term care claims and regulatory requirements.
Excellent decision-making, problem-solving, and analytical skills.
Effective verbal and written communication abilities, with a focus on clarity and professionalism.
Demonstrated leadership and coaching skills to develop high-performing teams.
Ability to manage multiple priorities and deliver results in a fast-paced environment.
Scope of Role:
Reports directly to Senior Management within the Claims Division.
Responsible for leading a large team or multiple teams across regions, lines of business, or profit centers.
Clear accountability for department-level results and contribution to organizational success.
Potential career progression to Assistant Vice President (AVP) or higher.
What We Offer:
Opportunity to lead a high-impact team within a dynamic and growing organization.
A collaborative culture that values innovation and professional development.
Competitive compensation and benefits package.
