The Director of Claims is responsible for the overall staffing, planning, fiscal management, administration, and operation of assigned claims functions, programs and activities including, but not limited to Claims Adjudication and Claims Provider Service. The Director will ensure that claims are processed in an efficient and accurate manner by establishing and enforcing department standards within a total quality management approach and in compliance with all applicable state/federal regulations.
The Director provides leadership and guidance for establishing production and work flow systems, setting production and quality standards, approving operating policies, procedures, and claims processing guidelines, coordinating with other departments to ensure that the claims function is achieves business, operations and reporting objectives, and assuring that CenCal Health goals are met.
Provide leadership to the Claims Department staff and establish objectives which ensure that the department goals and objectives are met
Supervise directly reporting staff
Oversee the interpretation and implementation of State and Federal statutes, regulations and mandates (including NCQA, HEDIS, HIPAA, Knox Keene,
DHCS, DMHC,) pertinent to claims processing function, while improving claims processes to yield operational efficiencies
Ensure the timely, accurate configuration of the claims sub-system and maintenance of claims coding databases; implement benefit, provider payment rate
updates, and dispute/appeal handling directives from regulatory agencies and Administration
Create updated Department policies and procedures as necessary
Ensure the efficient, timely, and accurate adjudication of claims; by maintain an adequate level of trained staff; revising operating workflows, and other
necessary changes to effectively implement changing CenCal Health policies and objectives
Develop, implement, and monitor programs and procedures to assure the efficient and timely submission of accurate encounter data to the State
Manage the volume and financial impact of pended claims, and status of subsystems maintained by Claims staff
Ensure staff is advised of all procedural changes in a timely manner, and that such changes are implemented promptly and effectively
Oversee the claims service functions and claims mailroom to ensure that responses to provider inquiries, disputes or appeals, and internal inquiries are
resolved accurately, promptly and with a high level of customer service