Presbyterian Healthcare Services
Director - Claims
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
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 directs 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 established quality and quantity standards. You will lead the encounters resolution team and be responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role drives the execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market-leading practices. The role champions and executes prioritized deployment of Auto-Adjudication methodologies, use of Robotic Process Automation (RPA/Bots), increases 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 improved functional effectiveness in departmental processes. This role uses 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 visualization tools (e.g., Tableau). Ability to summarize and clearly communicate ideas and processes, both orally and in writing.
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 department budget and is 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 encounters are processed according to pre-determined production and accuracy standards, within regulatory guidelines. Preparation and electronic distribution of desk top policies and procedures for both the Claims and Encounters department with support to Health Services, Member Services, Provider Services and Enrollment. Demonstrates advanced analytical and problem-solving skills as well as a system thinking approach to resolving complex benefit and provider process issues resulting from contract obligations. Support activities to resolving complex benefit problems, addressing cross-functional questions (e.g., from Configuration, Information Services, Claims, Encounters, Enrollment, Member Services, Provider Services, etc.). Regularly evaluate changes/updates of relevant information to facilitate further process improvement. Provides research, analytical, information support, and recommendations when requested for decision making. Assist in benefit and provider contract review to verify intent and assure consistency between the benefit/provider contracts and Operations activities. Assist in determining business needs by effectively conducting fact-finding interviews and leveraging various tools and analytical methods and then summarize findings to develop and propose appropriate solution. Support day-to-day consultation to business users and participate in cross-functional project teams. Support development and adoption of cross departmental analytics / dashboarding to provide visibility and decision support on impacted projects.
Benefits
We offer more than the standard benefits! Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more. Learn more about our employee benefits:
(note: benefits link provided in original text)
Senior ity level
Director
Employment type
Full-time
Job function
Hospitals and Health Care
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
Maximum Offer
Maximum Offer for this position is up to USD $77.90/Hr.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan and a growing medical group. More information about the organization is available in the original description.
#J-18808-Ljbffr
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 directs 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 established quality and quantity standards. You will lead the encounters resolution team and be responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role drives the execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market-leading practices. The role champions and executes prioritized deployment of Auto-Adjudication methodologies, use of Robotic Process Automation (RPA/Bots), increases 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 improved functional effectiveness in departmental processes. This role uses 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 visualization tools (e.g., Tableau). Ability to summarize and clearly communicate ideas and processes, both orally and in writing.
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 department budget and is 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 encounters are processed according to pre-determined production and accuracy standards, within regulatory guidelines. Preparation and electronic distribution of desk top policies and procedures for both the Claims and Encounters department with support to Health Services, Member Services, Provider Services and Enrollment. Demonstrates advanced analytical and problem-solving skills as well as a system thinking approach to resolving complex benefit and provider process issues resulting from contract obligations. Support activities to resolving complex benefit problems, addressing cross-functional questions (e.g., from Configuration, Information Services, Claims, Encounters, Enrollment, Member Services, Provider Services, etc.). Regularly evaluate changes/updates of relevant information to facilitate further process improvement. Provides research, analytical, information support, and recommendations when requested for decision making. Assist in benefit and provider contract review to verify intent and assure consistency between the benefit/provider contracts and Operations activities. Assist in determining business needs by effectively conducting fact-finding interviews and leveraging various tools and analytical methods and then summarize findings to develop and propose appropriate solution. Support day-to-day consultation to business users and participate in cross-functional project teams. Support development and adoption of cross departmental analytics / dashboarding to provide visibility and decision support on impacted projects.
Benefits
We offer more than the standard benefits! Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more. Learn more about our employee benefits:
(note: benefits link provided in original text)
Senior ity level
Director
Employment type
Full-time
Job function
Hospitals and Health Care
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
Maximum Offer
Maximum Offer for this position is up to USD $77.90/Hr.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan and a growing medical group. More information about the organization is available in the original description.
#J-18808-Ljbffr