Department: Payment Integrity - Operations
Reports to: VP Payment Integrity
Location: 4888 Loop Central Drive, Houston, TX 77081
Position is responsible for directing the claims department's processing activities in support of established production and quality standards. Incumbent will be responsible for leading a team of Sr. Managers and Managers, as well as oversee the strategic direction of the Claims Department.
Additional Responsibilities: Candidate Education:
- Direct and oversee claims processing activities with the objective of meeting production, timeliness and quality standards.
- Recruit, select, train and retain highly qualified professionals. Provide the senior leadership necessary to maintain a motivated, productive and competent team through open communication and delegation of responsibilities and authority.
- Identifies, defines and executes on opportunities for strategic improvement, including opportunities for increased auto adudication of claims.
- Participate with other health plan departments in planning, coordinating and problem solving in regard to claims operations.
- Direct and oversee claims activities to ensure that services comply with governmental and accrediting agency regulations.
- Partners effectively with business partners across the enterprise and within Operations (Configuration, Training, IT, etc.) to execute on critical business objectives and priorities.
- Ensure the delivery of superior customer services by providing timely and accurate claims payment and responding timely to member and provider inquiries and complaints regarding claims processing.
- Manages and develops direct reports who include other management or supervisory personnel and/or exempt individual contributors.
- Plans, conducts and directs work on complex projects/programs necessitating the origination and application of new and unique approaches.
- Defines strategic operational priorities and manages resources to operational goals and budgets.
- Develops strategies and ensures maximum efficiencies in the utilization of human and financial resources.
- Establishes the budget for the Claims Department and ensures adherence across the organization in conjunction with Finance and SVP, Operations.
- Ensures corporate initiatives are implemented to achieve optimum results.
- Perform other duties as assigned.
- Required A Bachelor's Degree in a related field
- Required or equivalent work experience
Candidate Skills: Licenses and Certifications: Technical Skills: Languages:
- Required 10 years of management experience in a managed care claims processing environment
- Required Other Extensive experience and leading edge knowledge of best practice claim processes, measurements, rewards and systems
- Required Other Experience in the selection and implementation of systems, and taking an active risk-taking role while implementing and achieving the savings/results
- Preferred Other Medicare risk and/or Medicaid risk experience