Director of Claims, Encounter, Analysis & Reporting

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.

This position will work in partnership with the Vice President of Operations and Director Claims Reimbursement and Oversight in a dually faceted role: (1) responsibility for creation and maintenance of claims analysis and oversight reporting, including, but not limited to, claims, MMCOR/SNPOR category of service, stop loss, and encounters (2) responsibility for project leadership working with a cross functional team driving claims, Encounter and Financial Reporting.

ESSENTIAL FUNCTIONS
Essential functions are job duties and responsibilities that must be performed to accomplish the purpose/ goals of the job.

• As the lead, develop, maintain and advance the success of Amida Care’s compliance with NYS APD/OSDS (includes creating new strategies, processes and policies around encounter submission). This work includes keen oversight of Amida Care’s TPA Encounter Process and Vendor Encounter Submissions, being Amida Care’s primary liaison with the NYS APD/OSDS Unit:
– Works closely with the Director of Vendor Management to oversee all specialty vendors with keen focus on Amida’s Care’s TPA to perform root cause analysis of claims/encounters processing and submission issues; develops recommendations based on data and industry knowledge. Collaborates with all Vendors to design and implement systems changes to meet encounter data processing and submission goals.
– Monitors inbound and outbound encounter process. Identifies and interprets encounter data, submission requirements and performance metrics.
– Provides specifications and works closely with IT, TPA and Specialty Vendors to develop various reports (i.e. Encounter Dashboards, exception reports, standard reports and performance reports). Distributes reports to appropriate departments for error resolution, follow up and performance monitoring.
• As the lead, develop, maintain and advance the success of Amida Care’s efforts with the NYS Stop Loss unit on stop loss recoveries (includes creating new strategies, processes and policies around Stop Loss reporting). This position works closely with Amida Care internal departments, as well as, NYS Stop Loss Unit.
• Act as Subject Matter Expert (SME) on the overall lifecycle of a healthcare claim, as well as state & federal reimbursement methodologies. This includes keeping Executive leadership aware of industry changes and/or any other outside variable that would directly affect Amida Care’s normal operation
• Work independently and collaboratively with the Vice President of Operations and Director, Claims Reimbursement and Oversight to document system enhancements, write specifications and requirements. Oversee the implementation process and assist in UAT testing and implementation if necessary
• Write specifications for the advancement of present reports on various areas of claims inventory (denials, pends, appeals etc.). Reports will be created with collaborative efforts and geared to the specific end users.
• Write specifications for the advancement of reports to evaluate volume trends, financial trends and any other outside variables which affect claim behaviors and industry KPIs (Key Performance Indicators).
• Support analysis and validation (become part of the QC process) of Amida Care’s claim processing vendors and their reporting efforts, including on inventory, payments, and accuracy.

• 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 or an equivalent combination of education and related experience.
• Minimum of five years’ experience in health care finance, operations and/or business analysis in Managed Care environment.
• Strong analytical and organizational skills.
• Advanced proficiency in Microsoft Office software (Word, Access, and Excel).
• Advanced proficiency using SQL, SAS, BI or any other appropriate analytical tool.
• Demonstrate 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.

*Please complete the Applicant Profile. Only applicants with completed profiles will be considered.
**All Amida Care employees are required to provide proof of full COVID-19 vaccination.

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