Claims Management Director

About the role

The Texas Health and Human Services Commission (HHSC) Medicaid & CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Director of the Claims Management unit. The Claims Management Director is selected by and reports to the Director of Provider Services within MCS Operations Management. The Claims Management area performs and oversees operations that support healthcare providers that participate in the Medicaid program. The primary functions of Claims Management involve oversight of Medicaid provider claims processing, payment, appeals and recoupments as well as operations of a call center to assist providers with service authorizations.

Ideal candidate

The ideal candidate thrives in an environment that emphasizes: teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.

Key responsibilities

• Operational Management (30%): Manages the day-to-day operational activities for Claims Management. Plans effective evaluation tools to determine and measure progress towards meeting the goals and objectives of the program. Reviews management, fiscal, compliance and productivity reports to ensure operational goals are met. Oversees the development of training plans and deliverables to meet current and new program activities and initiatives. Reviews guidelines, procedures, rules, and regulations and monitors compliance. Reviews results of internal audits or reviews to provide direction and guidance. Interprets state, federal and agency rules and policies as they apply to the program.
• Strategic Planning and Development (20%): Provides overall direction to the Claims Management unit to improve organizational performance, efficiency and effectiveness based on strategic goals and objectives. Evaluates the impact of proposed federal and state mandates on program objectives and plans short and long-term initiatives for compliance. Assesses current and future program automation and compliance opportunities. Evaluates agency priorities and other initiatives to identify dependencies and interagency impacts to Claims Management initiatives. Establishes processes to complete organizational goals effectively, and monitors processes for improvement opportunities, and implements improvement solutions.
• Technical/Communication Support (20%): Serves as a liaison between Claims Management and other external and internal stakeholders such as provider associations, the Texas Legislature, and other state and federal entities. Represents the program by making presentations; providing information to executive leadership; collaborating with consumer and provider advocacy associations, managed care organizations, other areas of HHSC, HHSC contractors, and other state agencies and federal partners. Responds to requests by legislators, auditors, attorneys, and other officials. Coordinates with federal and state agencies to ensure program policies, standards and activities conform to federal and state requirements.
• Project Management (15%): Oversees and/or manages the successful implementation of technology and operational projects including development, management, and approval of project deliverables, resources, and status reports for internal and external use. Assigns resources to projects as appropriate while managing competing priorities. Identifies and monitors status of external projects that affect Claims Management.
• Personnel Management (10%): Manages direct reports and their assigned tasks. Manages and develops direct and indirect reports through development of performance standards, review of performance data, consultation, training and mentoring, and performance appraisals. Promotes professional growth and development for staff. Responsible for hiring and selection, assigning work, completing performance evaluations, recommending personnel disciplinary actions, and scheduling and approving leave. Manages staff augmentation contractors who support the claims management unit.
• Other duties as assigned (5%).

Qualifications

Required

• Graduation from an accredited four-year college or university with major coursework in public administration, public policy, business administration, health care administration, social work, communications, or a related field. Relevant work experience may substitute for education on a year-for-year basis.
• At least five years of experience serving in a management capacity in the health services field that includes supervising staff.
• At least three years of experience with some combination of claims processing, payments, appeals and recoupments.
• Experience working in Medicaid programs.
• Experience delivering technical and non-technical presentations to various audiences and stakeholders.
• Experience responding to formal inquiries including legislative requests, audits, open records requests, and executive correspondence.

Preferred

• Contract management experience including participation in Requests for Proposals (RFP) or Requests for Offers (RFO).
• Experience with information resources technology project delivery policies, guidelines and standards.
• Experience managing or leading call center operations.

Knowledge, skills & abilities

• Knowledge of state and federal Medicaid program rules and policies.
• Knowledge of Medicaid provider recoupment, holds and appeals processes.
• Knowledge of public policy development and analysis.
• Knowledge of information technology systems, standards and practices used in Medicaid programs.
• Knowledge of state government legislative and budget processes.
• Knowledge of contract oversight and compliance.
• Knowledge of contact, help desk, or call center operations.
• Skills in public speaking to effectively solicit cooperation and to present highly technical information to a wide variety of audiences.
• Skills in written communications and presentations.
• Skills in conflict resolution, problem-solving, and making sound judgments under pressure.
• Strong analytical, strategic conceptual thinking, planning, and execution skills.
• Ability to balance team and individual responsibilities.
• Ability to manage complex operations involving people, information technology systems, and multiple vendor handoffs.
• Ability to build and maintain strong partnerships with internal and external stakeholders.
• Project and portfolio management skills.
• Ability to continuously learn and adapt to new concepts and evolving business needs.
• Ability to provide leadership and strategic direction for the overall planning and coordination in support of organizational objectives.
• Ability to lead and manage teams through staff selection, staff development, and performance management.
• Ability to work collaboratively across the organization with diverse teams and stakeholders to accomplish objectives.
• Ability to analyze processes, identify opportunities to improve them, and implement improvement solutions.

Benefits

• 100% paid employee health insurance for full-time eligible employees
• Defined benefit pension plan
• Generous time off benefits
• Numerous opportunities for career advancement