Claims Director, El Paso Health

Job Description:

Responsible for the oversight of departmental operations and implementation of all processes/work flows for accurate and timely adjudication of medical claims, correspondence and adjustment work, including processing all high dollar claims.  Serves as key claims liaison across all departments that impact claim operations and for transition/vendor initiatives. Accountable for policy and procedure development and execution, departmental maintenance/readiness for internal and external audits to ensure compliance with payment and billing regulations (i.e. HIPAA, Centers for Medicare Medicaid, Texas Department of Insurance, Texas Health and Human Services Commission, URAC standards etc.).  Implements industry best practices as they evolve.  Collaborates with administrative and executive leadership, as well as outside entities/vendors, to ensure organizational goals are met.

Required Skills:

1. Must be an effective leader and motivator of people with varying skill levels.
2. Ability to develop, mentor, and inspire staff to achieve consistently excellent results.
3. Ability to work successfully at a self-directed pace in a changing, high demand environment.
4. Ability to work successfully under tight deadlines.
5. Excellent communication (verbal, written, interpersonal) skills with the ability to deliver well-defined information to all level of management and staff.
6. Proficient in Microsoft Office suite products such as Word, Excel, PowerPoint and Outlook.
7. Effective analytical and program development skills as well as significant familiarity with managed care systems and processes.
8. Ability to make timely decisions with appropriate information and consultation.
9. Bilingual: English and Spanish preferred.

Required Experience:

Work Experience:
Five years of Management/Supervisory experience required.  Strong background working in managed care environment or delegated medical group claims management and managing high volume claims processing area required.  Comprehensive understanding and business application of healthcare industry practices included in Medicare, Medicaid and commercial plans required.  Must have medical claims experience, knowledge of claims systems and interdependent applications as well as detailed understanding of coding, medical, and health plan terminology.  Must have proven experience directing an operational function, preferably in a healthcare environment.  Experience with implementing and operationalizing Medicare Advantage plans highly preferred.

License/Registration/Certification:
Certification through the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) preferred.

Education and Training:
Bachelor degree in Business, Health Sciences or related field required.