Director of Claims

Director Of Claims Management

Denver, Colorado (Hybrid)

Full-time/Permanent + Benefits

Responsibilities

• Under the supervision of the VP of Operational Accounting, the Director, Claims is responsible for ensuring the delivery of timely and efficient claims service through the daily supervision of staff. This position provides technical guidance to staff regarding investigations, adjustments, complex claims, and review and implementation of workflow to individuals based on job type.

Essential Functions and Work Responsibilities

Functional Category: Claim Management

Estimated Percent of time Spent 80%

• Maintain a working knowledge of all regulatory and compliance guidelines that affect the scope of the department
• Responsible for the management and oversight of departmental functions such as claims adjudications, appeals, correspondence, claims adjustments, and claims support.
• Establish measures and processes by which to collect, monitor, evaluate, and report on key performance indicators
• Oversee staff and direct workflow in order to ensure claims are adjudicated within proper timeframes and payment of claims is executed in an efficient and timely manner.
• Ensure claims are paid correctly and timely by performing verification of contracts and utilizing claims software.
• Ensures appeals are correctly paid and recorded in claims software.
• Communicate and update management regarding issues affecting the claims department including software, refunds, timeframes, processes, etc.
• Assist with the evaluation and implementation of claims software including the management of software related issues.
• Research and manage services procured through third party vendors such as claims auditing.
• Prepare both recurring and ad hoc reports for management and other stakeholders requiring information regarding claims expenses, utilization or any other claims issues.
• Attend regular meetings and conferences with regulatory agencies and PACE associations to ensure client is compliant and following best practices.
• Act as claims representative on committees and project teams for purposes of planning and collaborating on company process improvements and expansion efforts.
• Work closely with operations and finance to partner on referral processes, IBNR accruals, encounter data submissions, and RAPS reporting.
• Work with IT team and various vendors to coordinate, manage, and implement change to improve efficiency, data accuracy/governance, and scalability
• Review, address, and resolve formal grievances directly pertaining to claims.
• Work as liaison with center directors and center staff to ensure excellent customer service, provider, and utilization management.
• Perform other special projects as assigned by company management.

Functional Category: Supervision

Estimated Percent of time Spent 20%

• Effectively supervises and manages direct reports and provides, by example and leadership, motivation and direction to employees of the organization.
• Carries out supervisory responsibilities in accordance with the organization's policies and applicable state and federal employment laws.
• Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; recognizing and rewarding employees; corrective disciplinary procedures and practices (under direction of supervisor and in partnership with Human Resources), addressing complaints and resolving problems.
• Ensure annual employee performance reviews are conducted in a timely and effective manner. Evaluates performance of employees for compliance with established policies and objectives of the organization and contributions in attaining objectives.
• Help set the tone of the department to ensure morale, team work, and the positive employment culture of the organization is maintained.
• Regularly schedules leadership/management, department, and staff 1:1 meetings to provide leadership, development, and a forum for communication to ensure coordination and collaboration in meeting organizational and individual goals.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

REQUIRED

Education

• Bachelors degree in accounting or a related field from an accredited college/university

Work Experience and Qualifications

• Minimum of ten years of experience in healthcare claims processing; or equivalent combination of education and experience.
• Experience with researching and resolving errors that result in refunds and adjustments required.
• Current experience and strong knowledge of co-pays, deductibles, co-insurance, coordination of benefits, pre-existing conditions, primary and secondary insurance and stop loss.
• Current experience and knowledge of general accounting, medical terminology, ICD-9, CPT coding, CMS 1500, UB2004 and other claim forms and systems.
• Strong familiarity and skill with Microsoft Office Suite, Check-writer System and Managed Claim Optimizer (MCO).
• Strong management skills and a minimum of two years of experience supervising staff.

Other Knowledge Skills and Abilities Required

Computer Skills

• Must be computer proficient and possess experience with Microsoft Word, Excel, and Outlook.
• Must be able to quickly learn specific software and new applications.

Mathematical/Financial Skills

• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
• Able to analyse data and statistics and draw reasonable conclusions and compile accurate reports.
• Experience with P/L and developing and managing budgets

Language Skills

• Ability to read, analyze and interpret regulations and other documents.
• Strong interpersonal skills and ability to effectively and tactfully present information to, and communicate with, co-workers, employees, and others.
• Possess exceptional English written and verbal communication skills, including accurate grammar and business correspondence knowledge.
• Ability to read and write memos, reports, and correspondence that conform to prescribed style and format.

Reasoning Ability

• Ability to define problems, collects data, establish facts, and draw valid conclusions.