Director, Claims

Position Summary

The Director, Claims is responsible for the development and execution of Claims operational strategies, end-to-end Claims process automation, optimization and management, identifying and leveraging technology and data to improve the quality and minimize process cost of Claims for all reseller client and self-insured employer client health plans. The Director, Claims will identify process improvement, conduct plan build and implement health plan designs for the claims system.

Responsibilities

• Ensure high service levels to members and clients through cost-effective, fair, accurate, consistent, and timely claims processing
• Establish and meet standards for timeliness and accuracy in claims
• Assure that claims management information systems, core claims and benefits processing systems, and reporting capabilities are accurate and up to date
• Create effective workflows, improve system efficiencies, and monitor quality performance measures
• Participate in the recommendation and development and implementation of claims policy, business strategy, and future technology enhancements involving Claims
• Oversee relationships with vendors that provide support to the Claims team
• Develop and maintain departmental policies and procedures
• Establish Claims objectives that support company goals and produce regular status reports
• Represent Claims operational perspective in the development of corporate business rules and initiatives
• Effectively communicate with other leaders in Operations and the Executive team
• Initiate personnel actions such as hiring, disciplinary actions, and salary recommendations
• Promote teamwork, discussion, and cooperation among staff and other teams
• Direct the design, planning, and implementation of training programs aligned with Claims objectives and strategies
• Perform other duties and responsibilities as assigned

Qualifications

This Director, Claims must be highly motivated and a self-starter. This individual must be a critical thinker and be able to grasp benefit concepts. The Director, Claims must be detail-oriented with the ability to manage multiple priorities and time-sensitive tasks. Excellent client services skills including verbal and written communication skills along with strong interpersonal and problem-solving skills are required. This individual must also possess an ability to work collaboratively in a team environment. To perform the position, an individual must be able to satisfactorily perform each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Education and Experience

• Must have completed a bachelor’s degree or have equivalent job experience
• A minimum of seven (7) to ten (10) years proven prior work experience in Claims Operations in a Health Plan (insurer), Managed Care, Self-Funded or hospital setting is required
• Familiarity with Eldorado Javelina claims processing system
• Must possess a thorough understanding of group medical claims, including ICD-10, HCPCS/CPT coding, HCFA 1500 and UB92
• Must have knowledge of claims editing and submission capabilities
• Proven experience as a strong leader that can make critical decisions based on data and experience
• Foundational knowledge of applicable compliance and regulations pertaining to claims operations
• Experience with planning and managing towards metrics and target performance goals

Certifications/Licensure/Registrations

Preference will be given to individuals who have completed the CEBS

Computer Skills

To perform this job successfully, an individual should have advanced proficiency in all Microsoft Office products and be able to learn new systems within a reasonable time. Javelina application experience preferred but not required.

Physical Demands

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 accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand, walk, use hands and fingers, talk, and hear. The employee is frequently required to sit and reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, crouch or crawl. The employee must regularly lift and/or move up to 10 pounds and occasionally lift and/or move 25 pounds or more. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The employee will work both in an office environment and remotely from home during typical office hours with occasional overtime. The office environment has moderate temperatures and minimal noise levels. When working remotely the employee must have a quiet, office-like work environment suitable for phone and web calls, and strictly adhere to HIPAA and privacy regulations. Occasional travel may be required.

Additional Comments

This job description is not intended to be a complete list of all responsibilities, duties or skills required for the job and is subject to review and change at any time, with or without notice, in accordance with the needs of Vitori Health LLC. Since no job description can detail all the duties and responsibilities that may be required from time to time in the performance of a job, duties and responsibilities that may be inherent in a job, reasonably required for its performance, or required due to the changing nature of the job shall also be considered part of the jobholder’s responsibility.