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HEALTHCARE CLAIMS OPERATIONS DIRECTOR


ROI SEARCH GROUP - HOUSTON, TX



Our client, a healthcare organization located in Houston, TX, providing their
clients with business services to obtain better reimbursements and streamline
operational activities, is looking for experienced Healthcare Claims Operations
Director. This position is full-time in the office 5 days per week.

The Healthcare Claims Operations Director is responsible for directing
operations of the Claims Department for Commercial and Medicare products. They
ensure that all functions related to claims receipt, processing and payment are
performed within the established quality and quantity standards. The Healthcare
Claims Operations Director drives strategic planning, operational excellence and
accuracy of the claims process and ensures compliance with regulations and
contract requirements for Medicare, Commercial, and Exchange service lines. The
Healthcare Claims Operations Director sets strategies for the claims units and
is responsible for integrating the various components of the business (software,
vendors, health plans) to ensure operational and developmental goals are
achieved. Healthcare Claims Operations Director also ensures the company is
completing both professional and institutional claim adjudications within the
appropriate CMS and/or State guidelines.

Qualifications:

 * Bachelor’s degree in related field.
 * Minimum 5 years of experience in claims administration experience in a Health
   Plan/IPA/MSO setting required.
 * At least 3 years of experience in a leadership position
 * In-depth understanding of legal regulations
 * Excellent analytical and problem-solving skills
 * Proven success in improving key performance metrics, including process
   improvement, cost reduction and improving efficiency.
 * Customer service background
 * Ability to organize, document, and control both digital and physical data

 Responsibilities: 

 * Responsible for overall operations of claims department.
 * Manages a team of adjusters, examiners, and vendors.
 * Ensures that all claims are processed according to pre-determined production
   and accuracy standards, within regulatory guidelines.
 * Accountable for the preparation and electronic distribution of desk policies
   and procedures for the Claims Department with support to Health Services,
   Member Services, Provider Services and Enrollment.
 * Responsible for provider inquiry call unit with associated performance
   measures related to wait time and accuracy.
 * Responsible for oversight activities for and associated with ECT (electronic
   claims submission) vendors that ensure contract terms are satisfied and
   ongoing.
 * Oversees all ECT (electronic claims transmission) activity.
 * Working with management to adjust procedures as needed.
 * Handling and processing official paperwork.
 * Directs development and implementation of processes to improve overall
   performance and accuracy of department.
 * Coordinates available resources to meet operational needs.
 * Collaborate with other departments such as UM, CM, Pharmacy, Eligibility,
   Performance Programs, Compliance, Configuration, Network Management IT Ops to
   drive operational excellence, including but limited to identification and
   implementation of Auto-adjudication rules, claims pend rules, claims editing
   rules, authorization rules, and contract rules.
 * Ensure Provider Disputes and Provider inquires/calls are resolved timely and
   accurately to assure conformity with internal, health plan and regulatory
   guidelines and requirements.
 * Determines methodology to reduce claims inventory. Regulates the current
   status of pended claims volume.
 * Monitors departments budget and are responsible for monthly variance
   reporting.
 * Enforces all company policies and procedures within department.
 * Ensure legal compliance of the claims processes.
 * Building and motivating the team to hit productivity goals.
 * Adjusting protocols based on company needs.
 * Attending educational sessions in the event of new laws or changing business
   directives.
 * Settling difficult or complex claims.
 * Works collaboratively with other areas to manage pending queue process,
   ensure optimal audit functions, and advocate for accuracy of reimbursement
   process.

 About ROI Search Group:

ROI Search Group is a 100% woman-owned staffing firm in Fishers, IN that offers
direct hire, interim, and contract staffing, while also providing executive
search, outplacement services, and training. We believe that people are an
organization's most important asset; therefore, our approach to attract the most
qualified passive talent is unique by design while supporting candidates
throughout their career. Drawing upon seasoned experience, ROI Search Group’s
proprietary methods provide a better understanding of client goals, job
requirements, company culture, while getting to know what’s most important to
our clients and candidates. Your goals are our goals, every single time.

 

 

Posted: Tuesday, December 6, 2022
Job # 582


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