Healthcare Claims Processing (Payor) Management, Director
Under the direction of the Vice President, Claims Administration, this position is responsible for directing all claims processing (payor) administration for the company.
Directly supervises and is responsible for departmental staff and claim processing operations.
This position is a Hybrid role, with most days from home, but times in the Frisco, TX, corporate office.
Candidate needs to live within a 90-mile radius of our Frisco, TX office.
Qualifications:
- Bachelor’s Degree in Accounting, Business, Healthcare Management or a related field
- 5+ years of insurance or healthcare or dental industry experience within Claims Processing Operations (Payor) management experience
- 5+ years direct staff management required including hiring, training, assigning work and managing performance
- Experience managing mid to large scale projects for improving processes or implementing new systems for billing and other related business processes
- Experience with management of application system vendors
- Experience with dental claims processing is preferred
- Advanced proficiency with computerized applications (Word, Access, Excel) and claims processing (payor) systems
- Excellent communication skills (written and oral) and strong organizational skills
- Strong customer service orientation
What you’ll be doing:
- Functional Lead of new system implementation that has just recently began
- Direct and oversee the operations of all claims processing (payor) administration functions to consistently meet the company’s operational and financial requirements
- Prepare departmental objectives, goals, workforce plans, and budgets
- Provide direction, supervision and support to all claims staff including the assistant director of claims administration and all claims processors in each division
- Responsible for retaining valued staff and replacing or hiring critical staff when applicable
- Develop staff capabilities to ensure coverage, cross-training and development through continuous evaluation and feedback
- Oversee claim determination, payment, complaints and appeals processes
- Ensure prompt payment of all claims and timely responses to member, provider and client inquires and appeals according to state, federal and contractual requirements.
- Develop and maintain departmental policies and standard operating procedures
- Ensure staff and cross-functional teams are informed and trained on changes in policies and operating procedures
- Develop inter-departmental reports and dashboards to routinely track metrics, identify trends and/or issues and to ensure all claims department tasks are performed with accuracy and timeliness
- Reduce errors and provide prompt issue resolution to prevent member, provider and client abrasion.
- Disseminate data reporting from various sources to management on a regular basis with attention to detail and accuracy including timeliness
- Monitor reporting and escalate issues to Vice President, Claims Administration and senior leadership as required
- Plan, develop and implement projects, processes and technology to improve and manage all claims administration operations and all related processes to continuously improve and manage its cycles and increase profitability
- Serve as functional lead for Claims Processing department initiatives
- Act as a key driver for change to support organizational growth initiatives
- Manage and direct the systems and processes for efficient and accurate claim reporting, billing and processing
- Responsible for working with IT leadership and staff on process improvement and optimizing the use of technology to automate
- Collaborate with other functional area leads including Member Services, Provider Relations, Operations, Account Management and IT to enhance cross-functional processes, to provide timely responses to issues, requests and complaints, and to implement new or revised in-house claims systems
- Collaborate with cross-functional leads, including Sales, to recruit and onboard new clients.
- Prepare monthly, quarterly and/or annual reports for clients
- Responsible for pulling, analyzing and correlating data from a variety of software applications and reports
- Prepare written comments as needed
- Keep abreast of client cost and advise other departments appropriately
- Performs other related duties as directed or deemed appropriate. Attend meetings as requested.
Source: Monster.com
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