Job Description
Location: Remote but must reside in New Mexico, California, Illinois, North Dakota, New York, Ohio, Washington, or Wyoming

Description:
The Director of Claims and Encounters provides strategic leadership, fiscal accountability and operational excellence for the Claims Operations and Encounter Resolution teams. This leader is responsible for directing 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 the established quality and quantity standards. You will lead the encounters resolution team and be the leader responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role is accountable to drive execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market-leading practices.

In addition to operational, this leadership role is accountable to champion and execute on the prioritized deployment of Auto-Adjudication methodologies, use of Robotic Process Automation (RPA/Bots), increased 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 improve functional effectiveness in departmental processes. This role will make use of deep claims and encounters expertise to improve the member and provider experience.

What You Will Do:

• 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 departments budget and are 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.
• Accountable for the 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.
• Responsible, on behalf of Operations, to support activities to resolving complex benefit problems, addressing cross-functional questions (i.e. from Configuration, Information Services, Claims, Encounters, Enrollment, Member Services, Provider Services, et al.).
• Regularly evaluate changes/updates of relevant information to the appropriate individual(s) 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 in a coherent manner to develop and propose appropriate solution.
• Support day-to-day consultation to business users and participate and contribute cross-functional project teams.
• Support development and adoption of cross departmental analytics / dashboarding to provide visibility and decision support on impacted projects.

You Will Be Successful If:

• 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 visualizations tools (e.g., Tableau).
• Ability to summarize and clearly communicate ideas and processes, both orally and in writing.
• Anticipating & Addressing Customer Needs
• Educating Employees, Customers & Transferring Knowledge
• Functioning as an Effective Contingent Member
• Diagnosing & Resolving Complex Problems
• Acquiring & Applying Superior Skills to achieve Quality Outcomes
• Functioning as an Effective Team Member
• Ability to present to various audiences

What You Will Bring:

• 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.