Director, Claims (Commercial-Self-Funded)

Responsibilities

• Directs all aspects of institutional and professional claims review for medical appropriateness and compliance with prompt pay regulations.
• Assists with the development, implementation, and updates to claims review procedures/criteria, physician and ancillary fee schedules and hospital contractual rates.
• Makes sure check runs and monthly reports are monitored to detect potential problems or issues.
• Collaborates with internal departments and participants on internal committees representing the claims department to formulate workflow between all departments.
• Hires and conducts annual employee performance reviews for direct reports.
• Monitors daily activities related to claims processing/review, productivity, timeliness of payments, and quality indicators of services.
• Conducts second reviews for Self Funded claims.
• Maintains and distributes reports as needed.

Requirements

• Required Bachelor’s Degree or equivalent experience.
• Experience in healthcare insurance operations.
• At least 5 years of previous claims leadership/management experience.
• Experience with medical claims payment, ICD-10, NDC, HCPCS.
• Strong analytical skills, including excell worksheets/formulas.
• Clear, concise verbal/written communication skills.
• Experience leading, formulating and delivering strategy, building strong connections with internal and external clients, customers, departments and teams.

Qualifications

• Demonstrates integrity and ethical standards.
• Accountable with ability to deliver on commitments and take ownership for solving problems and creating solutions.
• Strong, positive leadership skills.
• Desire for continuous improvement and innovation with the ability to embrace change and drive new ideas into business solutions.
• Experience with Project Management.
• Stop Loss Reporting & Tracking Experience.