Director, Claims / Req 788851521

PRINCIPAL RESPONSIBILITIES:

Under general direction from the Executive Director, Operations (ED, Ops), the Director, Claims provides strategic and operational direction for the effective management of claims payment, claims disputes and resolution, and claim recoveries for the Medi-Cal, Group Care, and Medicare D-SNP lines of business.

The Director is responsible for the overall development, planning, fiscal management, administration, and operation of assigned claims functions, programs, and activities. The Director will ensure that claims are processed and adjudicated in a timely and accurate manner by setting department goals and objectives within a total quality management approach and in compliance with all applicable state/federal regulations. The Director will provide leadership and guidance for establishing production and workflow systems, setting production and quality standards, defining all operating policies and procedures and claims processing guidelines, coordinating with other departments to ensure that claims payment functionality is operationalized to achieve business, operations, and reporting objectives, and assuring that Alameda Alliance goals are met.

Principal responsibilities include:

• Interact with all departments to ensure adherence of operational and regulatory/ contractual compliance for claims payment, dispute resolution, recovery, and designated audit activities.
• Coordinate with IT, Provider Services (Contracting, Network Data, Provider Relations) Compliance, Utilization Management, and other necessary departments to ensure that the claims payment system is configured and maintained appropriately to support accurate claims payments and adhere to state and federal regulatory requirements.
• Collaborate with Compliance and other departments, as necessary, in managing regulatory audits, inquiries related to the claims processing function, and department policy alignment.
• Assist the ED, Ops in implementing the organization's claims-related strategic goals.
• Assure the smooth transition of all claims-related systems changes from development to production including, but not limited to, system testing, configuration, written documentation of new or changed procedures, and training of staff.
• Optimize business processes and improve key quality metrics by conducting root cause analysis, identifying key areas for improvement, and developing and implementing system improvements.
• Manage vendors used to support claims-related processes, including, but not limited to, reviewing and modifying contracts, establishing and managing performance expectations, and periodically surveying market for alternative vendors. Collaborate with Director, Vendor Management as appropriate.
• Oversee and test contracted vendor tasks in relation to new contracts or configuration changes.
• Hire, coach, and develop staff to accomplish departmental and organizational objectives; provide appropriate direction, allocation, motivation, and evaluation of their work.
• Develop workflow processes to support goals and objectives relative to timely payment of claims, dispute resolution processes, recovery activities, and audits.
• Maintain and distribute a comprehensive dashboard of metrics and key performance indicators to ED, Ops related to claims turnaround, claims inventory, auto adjudication rates, EDI rates, interest payments, dispute resolution results, recoveries, and other relevant statistics.
• Work with the ED, Ops to develop plans for systems and staffing to meet current and future programs, requirements, and initiatives.
• Ensure that all Claims staff have the appropriate skills, expertise, and training to meet the ongoing business needs and initiatives and create future leaders and staff bench strength within the team.
• Provide leadership to the Claims management team in alignment with the Alliance's core values, building a high performing team and holding team members accountable for results in a culture of collaboration, trust, and respect.
• Participate and/or serve as leader in cross-functional teams as needed to identify and implement improvements in systems and/or enhancements for the administration of claims.
• Meet regularly with other Local Health Plans of California (LHPC) Claims Directors/Managers to discuss common issues and identify potential solutions.
• Keep abreast of any changes to legislation and regulations pertaining to claims
• Develop department budget as part of the annual planning process and review monthly to monitor adherence to established budget.
• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Oversee, write, and implement claims policies and procedures ensuring compliance with Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and/or other state and federal regulations as well as National Committee for Quality Assurance (NCQA) guidelines.
• Supervise staff assuring timely processing and documentation of paper and electronic claims.
• Hire, coach, train, and develop staff.
• Create and/or oversee the production of reports for the department, Senior Leaders, and Board of Governors on claim volume, paid, denied or pending claims, claims payments including interest, provider inquiries, and general production reporting.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Frequent data entry using keyboard and/or mouse.
• Frequent use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various other objects weighing between 0 and 30 Ibs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Number of Employees Direct Supervision: 2-10

Number of Employees In-Direct Supervision: 50-60

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor's Degree in a health-related field, or equivalent work experience.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum seven (7) years in a claims management or supervisory role with extensive hands-on oversight of workflow management and staff supervision required.
• Minimum five (5) years experience in a Medi-Cal and/or Medicare managed care claims processing environment strongly preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Experience in using a computerized healthcare claims processing system; knowledge of RAM HealthSuite a plus.
• Extensive knowledge of Medi-Cal and/or Medicare regulations related to the claims function.
• Experience with HIPAA and EDI transaction processing.
• Ability to facilitate meetings, manage complex initiatives, and make presentations before groups of management and staff.
• Possess a high energy level, be flexible and creative in managing daily operations, and be a fast learner.
• Excellent leadership, organizational, verbal and written communication, problem-solving, and customer service skills.
• Ability to gather, read, analyze, and interpret complex data and create accurate meaningful information for data reporting and decision support.
• A self-starter who is a hard driver and motivates staff to produce a high-quality product.
• A "hands-on" leader.
• Experience with claims auditing.
• Skilled at performing gap analyses between current processes/systems and optimal processes/systems and ability to identify solutions for more efficient operations.
• Experience with configuration and implementation of a claims processing system.
• Ability to perform business process re-engineering to maximize workflow efficiencies.
• Ability to develop, monitor, and adjust production standards.
• Possess strong project management skills.
• Full understanding of claims processes and financial impacts to assist with reporting needs (including IBNR calculations, Orange Blank reporting, and other reporting as needed).
• Proficient experience in use of various computer systems software including Windows, Microsoft Word, Excel, Outlook, Visio, and PowerPoint.

Salary Range $167,440.00 - $251,160.00 Annually

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. the Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious, creed, sex, gender, transgender status, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.

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