JOB TITLE: Claims Director
JOB CODE: 4069
The Director of Claims has overall responsibility of efficiently leveraging technology, and assuring delivery of a unique provider experience through accurate and timely payment of claims. In addition, this position provides leadership for the Claims department, and directs the operation of the claims function by processing payment for authorized services within Provider and Client contracts in compliance of State and Federal regulations.
1. Directs Operational functional areas that include specialized business units for Claims Examiners, Systems Configurations, Quality/Audit, Appeals and Reviews, Coordination of Benefits, Overpayment Recoveries, internal quality control, and provider customer service.
2. Implement and maintain efficient claims adjudication process that effectively utilizes technology to automate business processes and maximize the accuracy of claim payments.
3. Develop collaborative relationships with providers and other stakeholders with a focus on enhancing the service provided to members.
4. Proactively outreach to Providers and Field Operations to work to identify and resolve any payment or billing issues.
5. Ensure visibility and promote service in the Provider community to key Physicians and Facilities.
6. Provides guidance and establishes policies on health claims; maintain awareness of any changes to legislation and regulations which pertain to insurance claims.
7. Oversee and ensure that Claims Operations has the proper technology and operational systems.
8. Develop and maintain strong relationships with all key vendors that support Claims Operations, while holding vendors accountable for delivering their contractual commitments.
9. Manage the Claims Operations’ annual operating and capital budgets within industry standards and best practices in order to maintain an affordable and efficient cost structure.
1. Bachelor’s degree in business or related field from an accredited college or university.
2. Minimum of ten years of supervisory experience in a complex and diversified healthcare or health insurance company.
3. Substantial previous claims experience and understanding of claims operations specifically related to managed care.
4. Advanced knowledge of coding and billing processes, including CPT, IICD-9 and HCPCS coding.
5. Familiarity with a variety of field concepts, practices, and procedures
6. Strong working knowledge of Microsoft Office; specifically Outlook, Word, Excel, PowerPoint and Access.
7. Strong decision making/problem solving skills; strategic management skills
8. Ability to review data for analysis and trending reporting.
9. Ability to document and communicate claims system gaps, business processes and recommendations.
10. Proven organizational and prioritization skills; ability to effectively prioritize and execute tasks in a deadline driven environment.
11. Outstanding verbal and written communication skills.
12. Ability to interact professionally with providers and internal departments.
13. Ability to travel 10-15%.
No unusual physical requirements. Requires no heavy lifting, and nearly all work is performed in an
office environment. Specific vision abilities required by this job include close vision and ability to adjust
focus. Frequently required to sit, use hands/fingers to handle or feel, and talk/hear.