Director, Claims

The Job

Direct the strategy and operation of the Claims Department to ensure that claims are adjudicated in an efficient, accurate and timely manner and in accordance with Federal and State, Regulatory, as well as Plan standards. Fulfill the Claims Department mission by conducting thorough analysis, evaluation and disposition of claims to achieve superior customer service and claim results at the most reasonable cost. Ensure customer complaints and inquiries are resolved timely and accurately. Provide guidance and develop policies related to claims operations. Oversee and manager a team of various specialized skill sets and disciplines.

You Will

Oversee and provide operational guidance to the claim’s mailroom, claim’s production, claim’s audit, provider disputes, delegated claim’s resolution, recovery, member balance billing and compliance oversight functions within the department.

Provide interpretation of Benefits, Delegated Contracts, and provider contracts in matters regarding claim functions. Analyze and resolve escalated and / or complex member and provider claims concerns.

Lead activities related to internal and external audit responses. Develop and implement corrective action plans as necessary. Prepare reports by collecting, analyzing, and summarizing information and trends.

Attend various committee meetings regarding regulatory requirements, compliance, member and provider issues, and strategic planning. Monitor claims efforts internally and externally by auditing accounts and reports and directing new approaches.

Comply with federal and state regulations by studying existing and new regulations, legislation, and laws. Keep abreast of any changes to legislation and regulations which pertain to health insurance claims. Modify and / or develop internal policies and procedures to ensure operations remain in compliance.

Resolve non-standard claims by examining claims, policies, contractual responsibilities, regulatory guidelines, and other records. Determine company’s liability, negotiate settlements, and reach agreement with claimant according to contract provisions. Communicate with Senior Management regarding compliance and if needed, corrective action plan reports.

Achieve financial objectives by preparing an annual budget, approving appropriate expenditures, analyzing variances, and initiating corrective action plans to say on budget.

Build and maintain strong teams of internal and external resources that are technically competent and characterized by a high level of coordination and trust to resolve claim matters.

Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures. Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.

Utilize experience and judgment to plan and accomplish goals that are intended to drive the efficient, accurate, timely, and compliant claims adjudication function.

Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; and participating in professional societies.

Actively support the achievement of SCAN’s Vision and Goals.

Other duties as assigned.

Your Qualifications

• Bachelor's Degree or equivalent experience
• 6 to 8 years claims operations and / or systems experience with Medicare and Medicaid, including Medicare Pricing Rules and Fee Schedules, DRP, OPPS, bundling and third-party applications.
• Familiar with variety of the Medicare and Medicaid concepts, practices, and procedures.
• Knowledge of HIPAA transaction sets, regulations / privacy laws.
• Demonstrated management experience.
• Strong customer service skills.
• Strong communication (written and verbal), influencing, negotiating, listening and interpersonal skills to effectively develop productive internal and external relationships.
• Strong presentation skills to effectively address diverse audiences.
• Takes ownership and responsibility for decisions and outcomes.
• Leadership - Skilled to develops others
• Business Insight - In-Depth understanding of the business
• Problem Solving - Good problem solving skills
• Strategic Mindset - Creates strategies to sustain competitive advantage

What's in it for you?

Salary : $125 - $200