Healthfirst

The Claims Director will oversee all Claims Processing, Front End Operations and Outsource Vendor functions. The incumbent will be responsible for the accurate and timely processing of claims (both manual and auto-adjudicated). He/she will directly supervise Claims Managers that oversee inventory and processing of new claims and adjustments and carry out supervisory responsibility in accordance with the organization’s policies and applicable laws.

•Responsible for the oversight of claims processing workflow from time of receipt to final adjudication. Review status and inventory reports to ensure acceptable levels are maintained. Alert management to issues affecting timeliness and accuracy of processing and develop plans to address.
•Executes a continuous quality improvement plan on claim processing for corporate business. Work with management, claims analytics and the audit unit to gather and analyze data to identify opportunities to reduce re-work and medical cost.
•Understand underlying system set-up issues and offer recommendations for enhancements to improve auto-adjudication rates and efficiency of manual adjudication. Participate in system up-grades, automation modifications and any necessary model-office testing.
•Analyze claim receipts and develop strategies to increase electronic submission and auto-adjudication.
•Establish and maintain excellent working relationships with corporate departments and third party vendors. Actively participate in implementation of new business.
•Work with the Director of Training on the development of job-aides for processing all types of claims and encounters, perform periodic reviews and implement changes as dictated by changing business decisions.
•Actively participate in coordinating and outsourcing new/existing business to third party vendors.
•Responsible for achieving the corporate goals and metrics for claims processing in accordance with the organization’s policies and applicable laws.
•Participate in inter-departmental meetings and assess impact of issues discussed on claims processing.
•Assist with the development of performance standards and participate in performance calibration and evaluation reviews. Address staff complaints and resolve problems in conjunction with the Claims Managers.
•Review inventory reports while tracking and trending results to identify opportunities to improve overall claims processing.
•Conduct monthly presentations on the unit’s performance and results.
•Work with the Claims Analytics Director on the unit’s reporting needs, maintenance and support.

Minimum Qualifications:

- High school diploma or GED from an accredited institution. 

- Experience in a senior claims management role. 

- Demonstrated experience with workforce management. 

- Experience creating and providing presentations to cross functional groups within an organization. 

- Experience leading project teams and independent projects within specific timelines. 

- Experience providing evaluations and feedback. 

- Mathematical skills with proficiency in preparing and analyzing reports. 

- Experience creating and editing documents using MS Word. 

- Demonstrated experience creating, manipulating, and analyzing data in MS Excel using vLookups, pivot tables, etc. 

- Demonstrated experience in conflict resolution with staff. 

- Experience in monitoring and evaluating employee performance and providing feedback. 

- Previous hiring experience.

Preferred Qualifications:

- Bachelor from an accredited institution.

- Experience with Medicare, Medicaid and Commercial healthcare regulations.

- Knowledge of Medicare and Medicaid programs and reimbursement methodologies.

- Six Sigma Certification.

- Knowledge of Power MHS.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $150,800 - $230,690

• All Other Locations (within approved locations): $124,400 - $190,315

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.