Director of Claims & Enrollment

The Director of Claims and Enrollment provides leadership, direction, and subject matter expertise for the Claims and Enrollment Departments. The Director is responsible for the development and implementation of the strategies, systems and processes required to assure member enrollment and provider claims payments are appropriate and accurate. Actively collaborates with peers towards cross-departmental initiatives and fulfillment of the Plan’s strategic objectives. The Director is also responsible for policy & procedure development, budget, quality assurance, contract requirements, adherence to production standards and employee development. This responsibility will cover all product lines and all locations.

Key Functions/Responsibilities:

• Sets strategic direction and oversees day to day operations of the department.
• Directs managers and supervisors through coaching, professional development, work allocation, problem resolution, performance evaluation, and related supervisory activities.
• Manages the day to day operations of Member Enrollment and all activities related to eligibility and member-related data.
• Oversees the accurate and timely enrollment of all members, including ensuring that all contractual service levels are met including but not limited to:
o Timely reporting of eligibility and payment discrepancies, timely PCP assignments and coverage of newborns.
o Timely and accurate eligibility and financial reconciliation.
o Timely and accurate research and verification of member enrollment, eligibility and demographic data.
• Oversee efforts to manage and coordinate member reconciliation processes to ensure accurate member enrollment eligibility and payment.
• Designs and maintains a structured performance program for staff members — sets productivity and quality standards based on benchmarks, historical performance, and trends; tracks performances against standards and holds individuals accountable; motivates employees to exceed standards through an incentive program.
• Ensures departmental compliance with contractual, regulatory, NCQA, and corporate requirements, guidelines, and goals including turnaround times and reporting.
• Tracks trends, makes decisions based on organized information, and supports decisions with articulate written and verbal communications.
• Creates annual budget and is responsible for the budget oversight of department. Provides business justification for capital and resource needs.
• Responsible for cross organizational project leadership and provides representation for new products and initiatives.
• Documents and implements new policy; trains others in the critical success factors of the policy.
• Interacts with providers and business partners concerning escalated matters of significance and seeks win-win solutions.
• Represents the department to and takes direction from executives as necessary.
• Collaborates with peers and other departments to optimize payment accuracy, turnaround times, and other operational efficiencies. Lends subject-matter expertise to their initiatives.
• Vendor management responsibilities.
• Utilizes Key Performance Indicators to prioritize improvements efforts.
• On a timely basis, assure execution of control activities required for all BMCHP business lines.

Qualifications:

Education:
• Bachelor’s Degree or the equivalent combination of training and experience is required.
• Master’s degree in related field preferred.

Experience:
• Must have at least 10 years of managerial experience and progressively responsible experience in Medicaid, Medicare, managed care or commercial insurance.

Preferred/Desirable:
• Previous experience with the administration of Claims and/or Enrollment for a managed care organization, preferred.
• Hands-on experience using Trizetto Facets preferred.
• Medicaid experience preferred.
• Previous claims billing experience with a large hospital or physician group preferred.
• Occasional travel to provider audit sites.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

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