Director, Claims Reimbursement & Vendor Oversight

Amida Care is a Diversity, Equity, and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote, and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

The Director, Claims Reimbursement and Oversight primary responsibility is the coordination of all operational management activities related to oversight Amida Care’s TPA Claims Operations, as well as keen focus on specialty vendor claims performance. The Director will lead and coordinate all aspects of Health Plan-Managed Care claims processes and works closely with the Vice President of Operations and the Directors of all the Plan’s departments in order to effectively process and pay claims in a timely manner and in compliance with federal and state regulations. This position will continuously identify areas for reduction in healthcare costs without negatively impacting the provider network or the quality of care delivered to members

ESSENTIAL FUNCTIONS
Essential functions are job duties and responsibilities that must be performed to accomplish the purpose/ goals of the job.
• Lead and primary liaison between Plan and the TPA Claims Operation and Configuration Team
• Oversee and ensure accurate and proper execution of provider contracts/reimbursement configuration and implementation.
• Oversee the TPA’s end to end claim system process to ensure accurate and timely payments to providers.
• Oversee the accuracy of check runs, weekly claims inventory dashboard along with analysis on improving claims processing turnaround time and enhancing auto-adjudication rates.
• Oversee and analyze impacts of new program changes such as new benefits, new payment methodologies, new providers or new populations. Conduct analysis and create assessments of utilization patterns for individual provider entities and facilities.
• Key oversight responsibilities working directly with the Vice President of Operations to ensure claims are processed timely and accurately for specialty vendors, primarily the behavioral health vendor.
• Review existing claims reporting and work with the TPA and our internal IT department to develop additional reports and monitoring mechanisms as needed. Use these reports to aide in analyzing claims processing trends to develop metrics to track performance and further refine the service level agreements for the TPA and specialty vendors.
• Identify and document system enhancements and their requirements, as needed. Assist in UAT testing and implementation if necessary.
• Monitor and track governmental agencies for updates to annual and quarterly physician fee schedule updates and oversee the accurate and timely implementation into the TPA’s claims processing system. Assist with QA effort as appropriate.
• Work with network management to understand trends and baseline measures found in claims data to support reimbursement design/planning for prospective and current providers.
• Troubleshoot and identify claim-pricing errors in processing and work with internal departments, TPA and specialty vendors, including Correct Coding vendor, to achieve final resolution and process revision as appropriate.
• Work with network management to resolve provider claim and reimbursement challenges. Analyze provider billing habits and ensure providers are billing in accordance with contractual agreements.
• Responsible for the hiring and retention of quality staff and the on-going planning, monitoring, training, coaching, evaluation, and appraisal of staff performance and development to ensure successful achievement of goals and objectives.

MINIMUM JOB REQUIREMENTS

• Bachelor’s degree in business administration, healthcare administration or similar, or an equivalent combination of education and directly related experience in health insurance.
• Five years of medical claims analytical/process ownership or leadership experience with at least three years of claims leadership experience in NY Medicaid claims review and analysis.
• Cross department and outsourced vendor collaboration experience is strongly preferred.
• Demonstrate cultural humility and an understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization’s vision, mission, and values.

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