Director - Claims

Overview

The Director of Claims and Encounters provides strategic leadership, fiscal accountability and operational excellence for the Presbyterian Health Plan (PHP) Claims Operations and Encounter Resolution teams. This leader is responsible for directing the operations of the Claims Department for Commercial/ASO, Medicare and Medicaid products, to ensure that all functions related to claims receipt, processing and payment are performed within the established quality and quantity standards. You will lead the encounters resolution team and be the leader responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role is accountable to drive execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market-leading practices.

In addition to operational, this leadership role is accountable to champion and execute on the prioritized deployment of Auto-Adjudication methodologies, use of Robotic Process Automation (RPA/Bots), increased first pass and overall encounter acceptance and process simplification to achieve operational optimization and cost effectiveness. This role will lead department strategic objectives and have responsibility to achieve measurable gains in reduced cycle times and improve functional effectiveness in departmental processes. This role will make use of deep claims and encounters expertise to improve the member and provider experience.

This position is intended to be conducted in the state of New Mexico. 

Interested in learning more?

Text 505.388.0350 or schedule directly with me by clicking here! 

Qualifications

• Bachelors degree in Finance, business, healthcare or related field.
• MBA preferred.
• At least 10 years of healthcare specific operational leadership experience with a focus on Health Plan Claims Operations
• At least 5 years of experience leading in a similarly complex function.
• Ability to assimilate business group strategy/objectives to develop appropriate programs and solutions that support business goals. 
• Demonstrated experience navigating, influencing and leading within a highly matrixed environment.
• Advanced experience working on complex analytical projects with diverse teams and developing data driven and outcome-based initiatives to improve business decision making and operational efficiencies.
• Strong understanding of customer experience and lifecycle, as it relates to experiencing health plan benefits.
• Deep understanding of operations in the Health Care industry and a strong acumen of business processes, including operations, delivery models and revenue models.
• Content knowledge related to program outcomes evaluation, BI tools (e.g., BO), data visualizations tools (e.g., Tableau).
• Ability to summarize and clearly communicate ideas and processes, both orally and in writing.Skills:
• Anticipating & Addressing Customer Needs
• Educating Employees, Customers & Transferring Knowledge
• Functioning as an Effective Contingent Member
• Diagnosing & Resolving Complex Problems
• Acquiring & Applying Superior Skills to achieve Quality Outcomes
• Functioning as an Effective Team Member
• Ability to present to various audiences

Responsibilities

• Accountable for leadership of department managers and supervisors with responsibility for workforce planning, implementing process improvement initiatives and staff development.
• Leads and partners with business and technical subject-matter-experts on operational and transformational initiatives, in an agile manner, to enhance automation, innovation, process improvements, and maximize efficiencies across the continuum.
• Effectively translates strategic goals into specific operating and resource plans.
• Establish and maintain key claims and encounters KPIs to demonstrate operational performance.
• Drives continuous improvement activities in standard process, adjustor behaviors and claims outcomes.
• Maintains market leading claims and encounters quality assurance and testing center of excellence.
• Monitors departments budget and are responsible for monthly variance reporting.
• Ensures regulatory compliance across all areas of accountability, while delivering innovative and creative solutions that improve member experience.
• Drives contract NM Medicaid compliance to all appropriate encounters metrics and TATs.
• Manages key vendors to validate contract compliance on claims transactions and encounters receipt and acceptance measures.
• Ensures that all claims and e