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MetroPlus Health Plan: Senior Director of Claims

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MetroPlus Health PlanRussell, IA
  • 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 ClaimsManage 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 claimsManage the claims correspondence with providers and membersMinimum QualificationsBachelor’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 CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical skillsWritten/Oral Communication

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