Director of Claims

Responsibilities

• Lead process improvement initiatives within the department to achieve operational excellence and enhance claims services and outcomes
• Collaborate with functional leaders to define and implement strategies that support the claims organization’s goals and priorities
• Oversee the development and implementation of claims processing procedures and documentation to ensure accuracy, efficiency, and compliance
• Conduct ongoing reviews to maintain adherence to workflows and updates
• Serve as the primary contact for all departmental audits, including regulatory and internal audits related to claims operations
• Oversee contracted claims vendors to ensure effective administration of outsourced benefits and compliance with service level agreements and regulatory requirements
• Provide direct oversight of claims quality assurance and recovery program to ensure productivity and quality targets are established, met, and reported on for claims departments
• Establishes key service deliverables for turnaround times, quality assurance, and service experience
• Lead major departmental projects as assigned
• Assist in coordinating and monitoring reporting activities to issue key metrics related to goal attainment and policy and procedure enforcement
• Oversee appeal inquiries to ensure timely and appropriate responses
• Perform other duties as assigned at the discretion of senior-level management

Qualifications

• Bachelor’s Degree required, or equivalent years’ experience
• Minimum eight (8) years of progressively responsible experience overseeing a claims processing operation in a health care industry; to include six (6) years of supervisory experience
• Advanced knowledge of all types of health care claims processing, polices and procedures including benefit determinations and eligibility requirements
• Proven experience improving a Claims operation (reduction in pended claims, increase auto-adjudication rates, etc.)
• Experience developing strategic plans and metrics to measure level of achievement; thorough knowledge of claims operations and best practices required
• Outstanding communication, interpersonal and presentation skills required; able to foster good working relationships with staff, management, union, and other professionals
• Strong management and leadership skills required; able to coach, mentor, motivate and create improvement plans
• Excellent analytical skills, able to manage multiple projects under strict time-lines, work well in a demanding dynamic environment and meet overall objectives; strong attention to detail