Senior Director, Claims & Payment Integrity - Remote

Position Summary

The Senior Director, Claims & Payment Integrity, oversees health plan claims administration and payment integrity functions. Key responsibilities include driving quality, timely claims processing, inventory management, vendor oversight, and supporting audits and quality checks.

Job Description

• Drives quality, timely claims processing to achieve regulatory compliance, financial management, and product strategy outcomes.

• Oversees strong inventory management processes and enhances auto adjudication.

• Delivers strong vendor oversight to optimize system processing and improve efficiency and accuracy; pursues new vendor opportunities.

• Collaborates with business and IT teams for system and operational readiness.

• Ensures operational readiness, testing, training, reporting, and communications for claims processing updates.

• Acts as business owner for claims processing and edit vendors, overseeing vendor management, including day-to-day management, roadmap reviews, and joint operating committee management.

• Develops work intake mechanisms, exploring and implementing tools to manage claims processing tickets, prioritize backlog, and assess different work types.

• Remains up to date on industry trends and advancements in claims provider reimbursement and system technology to identify opportunities for improvement.

• Supports regular audits and quality checks to ensure data accuracy and system performance.

• Oversees the research, development, implementation, ongoing operational maintenance, and administration of provider payment methodologies and fee schedules for all provider types in support of provider contractual arrangements.

• Supports the development and integration of provider payment policies and guidelines applicable to institutional and professional reimbursements and in concert with the Organization's products and member benefits.

• Maintains all institutional and professional reimbursement methodologies leveraged by the organization, demonstrating deep knowledge in industry standard payment methods.

• Demonstrates working knowledge in the design and roll out of alternative payment methods focused on an incentive-based pay for value approach, partnering cross organizationally to support the development of these new programs and direct the operational activities necessary to stand them up.

• Researches and provides recommendations on development of new or enhancements to existing reimbursements in conjunction with corporate and contractual initiatives, including sound financial modeling/impact analyses.

Education/Experience

• Bachelor’s degree required; Master’s in business administration or comparable advanced degree strongly preferred.

• CPC Preferred.

• 10+ years health plan management experience required.

• Experience managing vended system applications.

• Experience with test plan development, strategy, and execution.

Skills/Knowledge/Competencies

• Demonstrates an understanding of and alignment with Martin’s Point Values.

• Maintains knowledge and understanding of reimbursement agreements as well as claims and billing practices that impact cost and utilization data.

• Develops and maintains positive, effective working relationships with colleagues, vendors, and other internal and external customers.

• Excellent workflow and inventory management skills.

• Excellent problem solving, quantitative, and analytical skills with the ability to assess performance against metrics.

• In-depth technical knowledge and ability to learn new technologies; knowledge of the Software Development Life Cycle (SDLC).

• Ability to manage, organize, and prioritize workload in a timely, accurate manner.

• Knowledge of industry standards for claims and enrollment configuration, reporting, and analysis.

• Knowledge of benefit coverage and servicing members, providers, and the DoD, CMS/ Medicare Advantage, and ME state insurance coverage.

• Knowledge of managed care computer systems, features, and reporting.

• Demonstrated interpersonal, communications, operational, team building, and quality improvement skills.

• Critical thinking: can identify root causes and implement short- and long-term sustainable solutions.