Claims Director

Description:

Verda Healthcare, Inc has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Claims Director to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare, Inc. and we will support you all the way.

Position Overview

A Claims Director manages employees, advises on claims litigation matters, identifies gaps in claims policies and procedures, and provides vision and direction for claims processing. Additionally, functions as a claims business application owner with input on overall design of the claims management system to improve efficiency and customer satisfaction while maintaining a low medical loss ratio.

The Claims Director will manage department staff including hiring, performance management and career development to ensure alignment with defined goals and be responsible for the creation, delivery and ongoing facilitation of a data and metrics-driven Claims Quality Assurance oversight program to ensure payment accuracy, which includes defining frameworks/benchmarks, calibration and reporting of a program towards set benchmark while promoting a continuous improvement culture. This person will oversee staffing and implementing and maintaining policies, procedures, and workflows across the Claims department that is compliant with State and Federal Regulations. The Claims Director is accountable for the coordination of internal and external claims payment integrity activities and fosters a strong team environment, collaborating with and supporting the Claims teams (Internal & External), Senior Vice President, COO and CEO as needed to ensure the Claims department is running at optimal performance.

Essential Functions

• Oversee the management of operations for the Claims Processing and Claims Payment Integrity departments.
• Coach and mentor operations management staff, provide professional development opportunities through work assignments, special projects, and performance feedback.
• Work with managers to develop and provide strategic guidance to improve key performance indicators and drive improved operational performance.
• Demonstrate a high degree of motivation, creativity, strong work ethic and flexibility.
• Work with the departmental managers to foster a strong commitment to member experience.
• Responsible for the attainment of CMS Service Level Agreements including quarterly EOB statements and frequent check runs on the core claims system.
• Ensure the core claim system includes all current CPT, HCPCS and diagnosis codes from Optum, and negotiate pro-rated discounts with the Optum team.
• Ensure the EDI Clearinghouse contract is optimized for cost efficiency including the elimination of paper claims to the greatest extent possible.
• Establish and successfully communicates Claims department goals and objectives together with individual goals and expectations; perform associate evaluations and provide coaching as appropriate
• Implement processes to ensure timely and accurate processing of claims.
• Provide statistical analysis of claims flow and production results.

Responsibilities

• Overseeing daily operations and senior level program management of the claims department.
• Assessing, evaluating, and reporting on staff as well as key business indicators.
• Ensuring meeting regulatory and CMS requirements at state and federal levels.
• Strategizing and implementing operational and structural changes with buy-in from senior executives.
• Manage Third Party Administrator (Wipro/InfoCrossing)
• Preparing, delivering, and presenting key claims reports at executive meetings.
• Ensuring that spending and budgeting are in line with business objectives and relevant legislation.
• Developing and managing the claims team so it follows all HR policies.
• Collaborating with various stakeholders to ensure company growth and stability.

Requirements:

Minimum Qualifications

• Bachelor’s degree required; Master’s degree preferred.
• A minimum of 5-7 years Health Plan claims operations experience in the delegated model setting; a minimum of 3 years in a leadership role.
• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation.
• Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.
• Experience with multiple health plan operational departments (i.e., configuration, medical management, provider operations, customer service, utilization management, regulatory, etc) a plus.
• Claims and configuration business process engineering experience preferred.
• Knowledge of health plan claims industry regulations, guidelines, requirements, and policies including claims edit, coding and claims terminology.
• Working knowledge of claims processing, correspondence and CRM platforms and adjudication strategies
• Demonstrated experience with claims testing/auditing/QA.
• Claims training experience or oversight preferred.

Professional Competencies

• Attention to detail
• Resource recruiting acumen
• Coaching/development
• Collaboration
• Communication
• Critical evaluation/thinking
• Decision making
• Ethical practice
• Initiative
• Judgement
• Leadership
• Prioritization/organization
• Problem solving/analysis
• Relationship management

Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time

Benefits:

• 401(k)
• Dental Insurance
• Health insurance
• Life insurance
• Paid time off.
• Vision insurance

Schedule:

• 8-hour shift
• Monday to Friday/Weekends as needed

Ability to commute/relocate:

• Reliably commute or planning to relocate before starting work (Required)

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

• Other duties may be assigned in support of departmental goals.