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Claims Director

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MetroPlus Health PlanRussell, IA
  • About NYC Health Hospitals MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • Position Overview The Senior Director of Claims has overall responsibility and accountability for effectively and efficiently leveraging staffing and technology in delivering the claims processing and claims service for MetroPlusHealth.
  • The position will direct strategic analysis and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial, Exchange and Medicaid service lines.
  • The incumbent sets strategy for the claims business units and is responsible for integrating the various components of the business to ensure operational and developmental goals are achieved.
  • Job Description Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements.
  • Direct and oversee all Claims Department functions including front end processing, adjustments, special pricing, recoupments, claims complaints, claims correspondence, benefit configuration, audit and testing
  • Establish administrative priorities and accomplishments for each area, manage area directors and managers.
  • Oversee and provide direction with the Director of Claims Manage the relationship with the TPA/BPO for claims processing.
  • Identifies, implements and maintains cross functional/departmental claims processes and policies.
  • Monitor claims inventory, cycle time processing and work quality to assure conformity with corporate objectives and goals.
  • Establish plans of action, allocation of resources, schedule overtime, etc., to ensure operational efficiency consistent with corporate and departmental goals.
  • Ensure adherence to all Legislative, Regulatory and Contractual requirements.
  • Conduct special projects including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing corporate requirements.
  • Coordinate and supervise operational analyses and implementation support on major workflow and activity modifications.
  • Recommend changes for system design, methods, and workflows affecting the assigned departments.
  • Develop, implement and maintain claims policies and procedures.
  • Liaison between claims and configuration to ensure claims rules are implemented and claims are processed accurately.
  • Act as a consultant for senior management from other departments for, but not limited to reimbursement methodologies, processing protocols and provider negotiations.
  • Manage the overall budget in support of the responsibilities of the areas and corporate initiatives and responsibilities.
  • Oversite of claims process of delegated vendors including but not limited to the TPA, dental vendor, vision vendor and other vendors for which claims is outsourced.
  • Oversee the testing and auditing of claims Manage the claims correspondence with providers and members Minimum Qualifications Bachelor’s degree or equivalent combination of education and work experience.
  • A minimum of 8 years senior leadership experience with at least 5 years of experience in claims management in the healthcare or insurance industry.
  • A demonstrated track record of driving the organizational and operational changes in the day-to-day business of a high-volume operation using current and new technology, achieving cost benefits and service excellence.
  • Professional Competencies Integrity and Trust Customer Focus Functional/Technical skills Written/Oral Communication

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