Director, Claims Operations Integrity

Role and Responsibility:
•Support all areas of Claims department for audits and project management impacts to Claims
•Liaison with all functional area leads within Claims, Configuration, Vendor Oversight and Delegation Oversight Committee, and Account Management Team
•Oversee all Integration activities for Claims department
•Participate in problem identification, resolution and monitoring of contractual performance guarantee parameters with delegated entities
•Maintain issue management tool and monitor issues through completion
•Liaison with Compliance and Privacy on regulatory issues; interact with SIU when suspect activity is identified
•Design and coordinate operational quality checks with Operational Excellence
•Design and deliver reporting for Compliance, Issue Management, Monitoring, and Vendor Report Cards
•Act as a liaison with IT to create a seamless ability for the business to leverage the services and expertise of the IT organization to obtain the business automation solutions necessary to ensure regulatory and compliance goals are met
•Facilitate the communication and understanding of business requirements between business areas and IT
•Support management information dashboards
•Maintain a working knowledge of management information system and coordinate required software enhancements for efficient claims processing
•Lead critical Claims department administration efforts, to include: preparation and monitoring of departmental budget to control cost effectiveness, assisting in the development and implementation of departmental policies and procedures and assuring theappropriate level of staff training is being conducted
•Maintains positive and strategic relationships with internal and external stakeholders
•Perform any other job related instructions as requested

Education / Experience:
•Bachelor’s degree in business or related field or equivalent years of relevant work experience is required
•A minimum of five (5) years of healthcare claims experience is required
•A minimum of five (5) years of leadership experience is required

Required Competencies / Knowledge / Skills:
•Advanced level experience in Microsoft Word, Excel and PowerPoint
•Data analysis and trending skills
•Familiarity with Claims concepts, practices and procedures
•Understanding of how claims payment methodologies, adjudication processing and State Encounter regulations interrelate to Facets and supporting systems
•Staffing and forecasting experience preferred
•Demonstrated understanding of claims operations specifically related to managed care
•Advanced knowledge of coding and billing processes, including CPT, IICD-9 and HCPCS coding
•Strong communication skills, to include proper grammar usage and phone etiquette
•Strategic management & leadership skills
•Ability to work independently and within a team environment
•Attention to detail
•Critical listening and thinking skills
•Negotiation skills/experience
•Technical writing skills
•Time management skills
•Customer service oriented
•Decision making/problem solving skills
•Medical coding or billing certification is preferred

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