Director, Claims Benefits Administration

The Director of Benefit Administration is responsible for the coordination of operational management activities related to plan benefits management to support system configuration, testing, and upgrades of the system. The Provider File Maintenance and Eligibility Maintenance operational units report directly to this position. Partner across the organization as well as with Claims Processing, Information Technology, Contracting and Network Provider Relations Regulatory Affairs, and Clinical Support. Develop and execute initiatives to enhance existing functions and evolve support of corporate/department processes and requirements.

Primary Responsibilities:

– Establish departmental goals, objectives and operating procedures.
– Provide leadership for oversight of Benefits in the claims system, as well as, Provider and Eligibility maintenance functions of the MCO, to ensure benefits, provider contracting data, and member eligibility aligns to all claims for payment accuracy.
– Identify and resolve operational issues using well defined/documented processes, expertise and judgment.
– Develop, implement, administer, and maintain benefit programs, policies and procedure to ensure the benefit meets Cardinal’s, State, and Federal guidelines
– Management of code sets to include but not limited to (ICD-10, HCPC, CPT, etc.)
– Oversee Plan Configuration to ensure adjudication rules align with contract.
– Direct the system testing to ensure continuous operations
– Develop benefit and system update communications to share with Cross-Functional teams
– Lead or assist in internal and external audits
– Monitor Provider Data and Enrollment transaction to ensure accurate and timely claims processing
– Monitor departmental processing activities to ensure that the MCO’s service, quality, productivity, service level agreements and goals are achieved.
– Serves as the MCO expert in the areas of provider billing, provider reimbursement, benefits, consumer eligibility and enrollment.
– Partner with business groups to develop, document and standardize procedures and workflows to support operational improvement.
– Liaison for senior management on systems operations, recommended changes for system design, methods, procedures and workflows affective claims operations.
– Leverage existing technology by identifying opportunities to automate processes and identify opportunities to incorporate new technology into process flows.
– Review, examine and provide leadership for the processing provider and eligibility issues.
– Partner with quality assurance department to provide feedback and corrective action on claims quality.
– Review and respond to regulatory updates impacting claims and member eligibility.
– Monitor weekly/monthly reports on claims activities; to ensure claims configuration and benefits are aligned accordingly.
– Manage the department to ensure the adherence to all MCO and departmental policies and procedures, as well as HIPAA regulations.
– Attend state meetings to stay informed of changes in local, State, Federal, and Division requirements.

Knowledge, Skills and Abilities:

– Knowledge of claims management, Medicaid, and State funding rules and regulations, third-party payers and coordination of benefits, eligibility verification and enrollment.
– Knowledge of physical and behavioral healthcare claims processing and business office operations billing procedures.
– Knowledge of CPT codes, ICD10 codes, and modifiers; certification preferred.
– Knowledge and understand basic medical terminology.
– Strong member focus that centers around advocacy and seamless client experiences.
– Knowledge of standard office procedures, practices and equipment.
– Ability to work independently, and communicate with associates, providers and general public.
– Knowledge of all types of health insurers and coordination of benefits preferred.
– Proficient in Microsoft Word, Excel and Outlook.
– Excellent oral and written communication and interpersonal skills required.
– Organization, time management, planning and project management skills, ability to manage multiple priorities to meet deadlines.
– Ability to think both tactically and strategically in addressing issue resolutions.
– Excellent problem-solving and analytical skills.
– Ability to create/analyze reports and utilize data to drive results.
– Must be team-oriented and able to interact effectively with other staff.
– Knowledge of a capitated managed care environment.
– Knowledge of Tailored or Specialty Plans

Education and Experience:

– Bachelor’s degree accounting, business administration, health or related field
– 8+ years of experience in management with considerable experience handling claims, accounting, business, finance, billing and collections or equivalent combination of education and experience.
– Experience in implementation of Benefit Management
– Experience in the public mental health field or a management care organization is highly desired.
– Experience in specialty plans, integrated care and Medicare also a plus.
– Licensure and/or Certification: CPT codes, ICD10 codes, and modifiers; certification preferred

Valid Driver’s License Required: Yes

Travel Type: Domestic

Percentage: 5 – 15

Equal Opportunity Employer/ Protected Veteran/ Individuals with Disabilities

Cardinal Innovations is firmly committed to the policy of providing equal employment opportunity (EEO) to all of its employees and applicants for employment without regard to race, age, color, sex, religion, creed, veteran status, genetic information, national origin, non-job related disability, sexual orientation, and/or gender identity or expression (except as mandated by law). Employment at Cardinal is based solely on a person’s merit and qualifications directly related to professional competence. For that reason, we consider qualified applicants regardless of criminal histories, consistent with legal requirements. Our equal employment opportunity philosophy complies with federal, state and local law and applies to all aspects of employment with Cardinal, including recruiting, hiring, training, transfer/promotion, compensation, benefits and termination.

If you have a disability or special need that requires accommodation, please let us know by contacting Cardinal’s Human Resources department at Someone from the HR team will reach out to see how we may be able to assist.

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