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 Ability to work a flexible schedule #J-18808-Ljbffr