Director, Claims Operations

Director of Claims Operations As the Director of Claims Operations, you will direct the strategy and operation of the Claims Department to ensure that claims are adjudicated efficiently, accurately, and timely and in accordance with Federal and State regulations, as well as plan standards. Fulfill the Claims Department mission by conducting thorough analysis, evaluation, and disposition of claims to achieve superior customer service and claim results at a reasonable cost. Ensure customer complaints and inquiries are resolved in a timely and accurate manner. Provide guidance and develop policies related to claims operations. Oversee and manage a team of various specialized skill sets and disciplines. Oversee and provide operational guidance across mailroom, production, audit, provider disputes, delegated claim resolution, recovery, member balance billing, and compliance oversight functions. Provide interpretation of benefits, delegated contracts, and provider contracts in matters related to claim functions. Analyze and resolve escalated and/or complex member and provider claim concerns. Lead activities related to internal and external audit responses. Develop and implement corrective action plans as necessary. Prepare reports by collecting, analyzing, and summarizing information and trends. Attend various committee meetings regarding regulatory requirements, compliance, member and provider issues, and strategic planning. Monitor claims efforts internally and externally by auditing accounts, reports, and directing new approaches. Comply with federal and state regulations by studying existing and new regulations, legislation, and laws. Keep abreast of any changes to legislation and regulations that pertain to health insurance claims. Modify and/or develop internal policies and procedures to ensure operations remain in compliance. Resolve non-standard claims by examining claims, policies, contractual responsibilities, regulatory guidelines, and other records. Determine company’s liability, negotiate settlements, and reach agreements with claimants according to contract provisions. Communicate with Senior Management regarding compliance and if needed, corrective action plan reports. Achieve financial objectives by preparing an annual budget, approving expenditures, analyzing variances, and initiating corrective action plans within budget. Build and maintain strong teams of internal and external resources that are technically competent and characterized by coordination and trust to resolve claim matters. Accomplish staff results by communicating job expectations, planning, monitoring, and appraising job results, coaching and counseling employees, initiating, coordinating, and enforcing systems, policies, and procedures. Maintain staff by recruiting, selecting, orienting, training employees, maintaining a safe and secure environment, and developing personal growth opportunities. Utilize experience and judgment to plan and accomplish goals that drive efficient, accurate, timely, and compliant claims adjudication. Other duties as assigned. Qualifications Bachelor’s Degree or equivalent experience. 6 to 8 years of claims operations and/or systems experience with Medicare and Medicaid, including Medicare Pricing Rules and Fee Schedules, DRP, OPPS, bundling, and third-party applications. Familiar with a variety of Medicare and Medicaid concepts, practices, and procedures. Knowledge of HIPAA transaction sets, regulations/privacy laws. Demonstrated management experience. Strong interpersonal skills, including excellent written and oral communication and a strong commitment to detail. What’s in it for you? Base Pay Range: $147,900 - $214,030. Salary Work Mode: Mostly Remote. An annual employee bonus program. Robust Wellness Program. Generous paid‑time‑off (PTO). 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days. Excellent 401(k) Retirement Savings Plan with employer match. Robust employee recognition program. Tuition reimbursement. An opportunity to become part of a team that makes a difference to our members and our community every day. Equal Employment Opportunity Statement SCAN is proud to be an Equal Employment Opportunity and affirmative action workplace. Individuals seeking employment will receive consideration regardless of race, color, national origin, religion, age, sex, sexual orientation, gender identity or expression, marital status, disability, protected veteran status, or any other status protected by law. A background check is required. #J-18808-Ljbffr SHPCA SCAN Health Plan