Director, Claims Operations - Remote

Company Description

WHO IS GUIDEHEALTH? 

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. 

Job Description

As the Director, Claim Operations, you will play a key role in Guidehealth’s expansion and growth.  You will provide operational oversight of the Delegated Claims Operational departments which include Claims Production, Inquiries, Appeal and Disputes, System Configuration, Eligibility and Offshore Project management.  

WHAT YOU'LL BE DOING

• Direct supervision of the individual department managers, including hiring, training and evaluating their performance.
• Maintains and improves all claim operational functions by monitoring system performance; identifying and resolving problems; preparing and completing action plans.
• Compile, review and analyze data, metrics, KPIs to inform leadership to assist with business decisions and improvement of processes.  
• Oversee the managers’ responsibilities with writing and maintaining desktop procedures within each department to ensure they are up to date and accurate.
• Identify areas within the operations workflow and system tools where improvements or enhancements can be completed to drive positive outcomes. Monitor those changes to ensure increased efficiency and production.
• Leveraging technological advantages and incorporating new workflows to scale the business.
• Conduct weekly and monthly staff meetings at direct reporting and indirect levels.
• Write new policy and procedures and submit the to the committee for approval.
• Participate in the Monthly Policy and Procedure committee meetings, responsible for the review and approval of new or updated policies from all departments.
• Vendor management, negotiations and AR approval.
• Financial budget review of each department.
• Ensure compliance with state and federal regulations and company policies.
• Provide expert advice and guidance to other employees and senior management on other teams.
• Oversight of the configuration of the system from the standpoint of eligibility, system benefit configuration, fee schedules and provider maintenance.
• Attend operational leadership meetings.
• Present KPI, Benchmarks and Metrics at leadership meetings.

Qualifications

WHAT YOU'LL NEED TO HAVE 

• Minimum 3 - 5 years’ experience in Management of claim operations and proven leadership skills.
• Certified Professional Biller (CPB), Certified Professional Coder (CPC), or other similar certifications.
• Advanced knowledge of claim processing including claims data analysis, and the setting, tracking and reporting on performance metrics.
• Proficient with Microsoft applications, Excel, Word, Access and Power Point.
• Experience with EDI transactions.
• Strong understanding of healthcare regulations, insurance contracts, and reimbursement processes.
• Ability to work independently with minimal supervision. Exceptional judgement in escalating concerns to next level leadership.
• Exceptional written, visual and verbal communication is necessary to lead a team and convey clear instruction.
• Comfortable with public speaking.

WHAT WE'D LOVE FOR YOU TO HAVE

• Bachelor’s degree in healthcare administration, business, or related field
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.

Additional Information

The salary for this role is up to $105k per year based upon experience and skills.

ALIVE with Purpose: How We Thrive at Guidehealth 

At Guidehealth, our values come to life in everything we do. 

• We are Driven by Accountability — grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike. 
• Always Growing, Always Learning — staying curious and continuously improving inspires us to shape a better future for healthcare. 
• With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve. 
• At Guidehealth, Every Vo