Director, Claims(Preferred Experience in Medicare and Must Live In New York) - R12378

ElderServe Health is a mission-driven, nonprofit managed care organization serving the New York metropolitan area. ElderServe provides long-term services and supports to more than 20,000 older adults and adults with disabilities across New York City, as well as Westchester, Nassau, and Suffolk Counties. ElderServe primarily serves a frail and elderly membership who is predominantly dual-eligible and enrolled in Medicaid managed long-term care, Medicare-only and integrated Medicaid-Medicare plans. The CareSource and ElderServe affiliation addresses these critical long-term care needs to help members be as healthy and independent as possible.Job SummaryThis position is responsible for directing the overall functions of claims processing, including claims adjudication, provider relations, data analysis, reporting and process improvement. Provides oversight and supervision of the claims team.Essential FunctionsResponds to complaints in a prompt and professional manner and deploys effective service recovery strategies to resolve the issue. Escalates unresolved complaints when appropriate.Direct and coordinate the activities of claims and data entry areas including direct supervision of subordinates and the implementation of employment issues.Maintenance of a working knowledge of Management Information System and the coordination of required software enhancements for efficient claims processing.Assisting in the development and implementation of departmental policies and proceduresAssurance of appropriate level of staff trainingMonitoring and documenting processing accuracy and productivity levelsPreparing, submitting and monitoring various reports as requiredOversee Medicare audit preparation, submission, and response processes, ensuring compliance with CMS regulations.Review, track, and manage Medicare audit findings, coordinating corrective action plans and validation activities.Ensure accurate Medicare coding, documentation integrity, and adherence to billing rules to minimize audit risk.Responsible for managing and responding to claim appeals, including Medicare-related appeals, ensuring timely and accurate resolution.Establishing department audit process and payment integrityPerform any other job related duties as requested.Education and ExperienceAssociates in business or related field requiredBachelor's degree preferredEquivalent years of relevant work experience may be accepted in lieu of required educationFive (5) years of healthcare claims experience requiredPrevious financial experience in MLTC preferredThree (3) years Previous leadership experience requiredExperience with Medicare coding standards (ICD-10, CPT, HCPCS) and Medicare audit processes requiredCompetencies, Knowledge and SkillsAdvanced proficiency in Microsoft Word, Excel, and PowerPointData analysis and trending skillsExperience in staffing and forecasting (preferred)Understanding of managed care claims operationsKnowledge of coding and billing processes (CPT, ICD-9, HCPCS)Strong communication and negotiation skillsStrategic and executive management abilitiesSupervisory and leadership experienceAbility to work independently and collaborativelyAttention to detail and critical thinkingFamiliarity with the healthcare fieldTechnical writing and proper grammar usageEffective time management and decision-making skillsCustomer service orientation and proper phone etiquetteLicensure and CertificationMedical Coding or billing certification preferredWorking ConditionsGeneral office environment; may be required to sit or stand for extended periods of timeTravel is not typically requiredCompensation Range$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.Compensation TypeSalaryCompetencies Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.