Director, Claims Encounter Data

Role and Responsibility:

Oversight of corporate Claims Encounters regulatory reporting
Coordination and direction of the activities of business trading partner strategy and relationships and Encounter data management functions, including direct supervision of employees
Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to maintain compliant Encounter reconciliation processes and SLAs
Responsible for Claims Encounter Data process for both CMS and State agencies
Responsible for other key claims data management and readiness to state and governing entities
Ensure department meets claims data submission requirements
Responsible for identifying areas of improvement and streamlining procedures and policies to ensure effective and efficient workflows
Understand and coordinate business transactions for all HIPAA standard sets
Coordination of required software enhancements for efficient encounter data systems
Preparation and monitoring of departmental budget to control cost effectiveness
Management of forecasting and workforce management models to ensure appropriate level of staffing and training
Assisting in the development and implementation of departmental policies and procedures
Provides critical reporting and analysis of functional performance, and make recommendations for enhancements, cost savings initiatives and process improvements
Preparing and monitoring various management and oversight metrics & reports as required
Business owner for oversight of encounter data and trading partner vendors, managing SLA’s, regulatory requirements and contractual metrics
Lead a strategic and tactical internal team focused on delivering operational efficiencies through technology automation and workflow efficiencies
Ensures quantitative and qualitative objectives are used to meet department performance objectives
Collaborates with other departments to improve quality to CareSource members through implementation of quality initiatives and efficiency improvements; ensures that processes are documented and that appropriate quality measures are implemented
Provides vision and leadership to facilitate the development of cross-functional work teams, and participate in the on-going development of new products and technology within areas of responsibility
Maintains positive and strategic relationships with internal and external stakeholders
Actively participates and partners with vendor management and procurement to secure effective and efficient vendor contracts
Participates as a member of the Business Partner Operations (BPO) senior management team to develop strategies and goals for the organization
Perform any other job related instructions, as requested
Requirements
Education / Experience:

Bachelor’s Degree or equivalent years of relevant work experience is required
Minimum of five (5) years of experience with a health care claims and/or encounter data department is required
Minimum of five (5) years of leadership experience is required
Experience managing vendors to contractual requirements is required
Required Competencies / Knowledge / Skills:

Demonstrated understanding of claims operations specifically related to managed care
Effective identification of business problems, assessment of proposed solutions to those problems, and understanding of the needs of business partners
Knowledge of regulatory reporting and compliance requirements
Excellent interpersonal skills and the ability to influence and work with external stakeholders to mutually benefit each organization and 3rd party constituents
Support the development of effective working relationships with business partners
Demonstrated competencies with direct and indirect management of exempt and non-exempt staff
Effective communication and interaction skills
Working knowledge of health care/managed care or similar heavily regulated environment
Strong financial acumen preferred
Licensure / Certification:

Six Sigma certification or similar methodologies is preferred

Position Description »