Director, Non-Contracted Provider Claim Appeals

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Director of Non-Contracted Provider Claim Appeals assumes a vital role in delivering strategic leadership and oversight for the management of the non-contracted provider claim appeals. Ensures consistent regulatory compliance and meeting company objectives as they relate to the resolution of non-contracted provider claim appeals. Ability to collaborate with internal stakeholders and delegated entities to ensure timely and accurate resolution of provider appeals. Leads, supports and empowers the Appeals team while also being accountable for performance management, quality improvement and operational accuracy. Provide vision and direction for the department, aligning goals with organizational objectives and priorities.

RESPONSIBILITIES: 
1.    Ensures proper controls are in place to consistently meet compliance in all areas of claim appeals and operations. 
2.    Drives operational excellence into all processes using established key performance indicators and metrics.
3.    Drives high-quality execution and operational excellence by communicating clear directions and expectations.
4.    Builds and maintain strong working relationships with internal and external stakeholders. 
5.    Ensures timely reporting of all required ODAG submissions for Compliance and CMS monitoring.
6.    Accountable for periodic review and update of appeal policies, notice templates and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.
7.    Develops and execute strategic plans and initiatives to improve processes.
8.    Partners with other functional leaders and serve as the primary point of contact for senior leadership, delegated entities and regulatory agencies on matters related to claim appeals.
9.    Effectively collaborates with other leaders in the organization in improving interdepartmental processes.
10.    Develops and mentor team of claim appeals professionals, fostering a culture of collaboration, accountability, compliance, and professional development.

Supervisory Requirements:

Fulfill supervisory responsibilities in accordance with organization policies and applicable laws.  Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Job Requirements:

Experience:

• Required: Minimum 7 years of progressive leaderships experience in claim appeals and disputes management. 5 years of Experience with regulatory compliance oversight related to non-contracted provider appeals and disputes processes, in both delegated and non-delegated managed care environment. Previous experience in setting up training programs and motivating employees in a high-volume transaction processing environment.

• Preferred: 5 years leadership experience in a Medicare Health Plan setting.

Education:

• Required: High School Diploma or GED.  Bachelor's degree or four years additional experience in lieu of education.

• Preferred: MBA

Specialized Skills:

• Required:

• Knowledge of healthcare claims operating, and provider appeals and disputes systems and capabilities to identify, recommend and implement new or improved technology.
• Demonstrated knowledge of CMS Reporting (ODAG, Stars Measures, etc.,)
• Exceptional leadership, interpersonal, analytical, and communication skills
• Innovative in problem solving, planning, and strategizing.
• Demonstrated record of generating results and having an impact on organizations.
• Demonstrated forward thinking in areas of technology support, operational transaction processing and leadership.
• Proficiency in Microsoft programs. Intermediate or advanced level proficiency with Microsoft Excel, Word, and PowerPoint.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills:  Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills:  Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills:  Comprehend and analyze statistical reports.

Licensure:

• Required: None

Essential Physical Functions:

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

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $113,332.00 - $169,999.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.

Salary : $113,332 - $169,999