Do you have the desire to be part of a growing, agileClaims Operations team? Is a culture where “People Count”, “We do the Right Thing” and “We Hold Ourselves to Very High Standards” important to you? If so, Avesis Incorporated is actively seeking a passionate, driven Director, Claims Operations to be responsible for the planning, organization and management of claims processing operations. Routine responsibilities include managing day-to-day operations of each of the company’s claims department functions and staff which includes prior authorizations and determinations (clinical and administrative), claims adjudication along with appeals, grievances and complaints.
This role routinely works with staff from other divisions within the company regarding current claims activities; planning and implementation of claimssupport for new clients and contracts; analysis of claims volume, issues and content for identification of performance or payment trends; system configuration and automation (including robotics) to continually improve efficiencies and operational costs; and staying abreast of legislation and regulations relative to healthcare insurance claims and initiating procedural or company policy changes as applicable.
The Director will routinely interface with external vendor partners and clients as well as internal teams including provider relations, account management and audit regarding the claims process, systems applications, and related topics.
Additionally, the Director is responsible for ongoing evaluation of all aspects of claims operations, procedures and internal processes to identify and implement process improvements that will enhance the functionality and cost effectiveness of the department.
- Understands Avesis’ health plancontracts and contractual performance requirements, all aspects of claims processing work flow and payment process, and a thorough knowledge of diagnosis and procedural coding for vision & dental claims.
- Leads the strategic planning and execution of initiatives for Avesis Claims Operations. Ensure optimal claim management results, including return to work efforts, positive claim outcomes, and consistent best practices.
- Establishes key service deliverables for turnaround times, quality assurance and key stakeholder’s service experience.
- Manages department budget combined with annual reforecasting efforts. Delivers on key financial metrics toward achieving Group Profit Center loss ratio objectives.
- Leads projects intended to improve operational excellence and enhance claims services and results.
- Implements programs to ensure attainment of business plan for growth, profit and key service deliverables.
- Skillfully uses Avesis systems and applications for provider network and member data, utilization management, claims adjudication, appeals/grievances/complaints, and customer service. This includes working directly with the system configuration team to assure a high degree of auto determination and auto adjudication.
- Oversight and management of the claims and UM documentation process, including electronic prior auth and claims receipt, determinations, adjudication and payments; receipt and imaging of hardcopy claims & prior authorizations and correspondence received through the mail; manual processing by claims department staff; and oversight of preparations for check runs and payments to providers and members as applicable.
- Oversight of the training, development and operational/productive capabilities of the claims operations department staff to execute their processing responsibilities for productive output, quality and accuracy of processing, and timeliness of work being performed. Actively provides candid developmental feedback.
- Develops and inspires the team by providing business updates that align the team's objectives with the goals of the organization while maintaining an environment of trust. Creates a culture of openness, trust and inclusion.
- Executes Performance Management Cycle-Establishes performance metrics with clear systems of measures and accountabilities that drive results.
- Exhibits effective leadership skills, including strategic understanding of risk management, vision for change to compete in a dynamic market environment and people management skills to succeed in a collaborative, team-oriented culture
- Adapts to and supports changes in contractual performance requirements, company policies and procedures.
- Establishes consolidated and consistent processes and relationships with internal stakeholders and external partners to support Av?sis in achieving its strategic and tactical business objectives.
- Reviews and approves Claims Department staff vacancies, consistent with budgetary guidelines for department headcount.
- Maintains effective intradepartmental communications through sharing of plans, general company news and other information through informal interactions and routinely held departmental meetings.
- Bachelors’ degree in healthcare administration, healthcare, business, or a related subject area.
- At least 8 years’ experience managing healthcare claims; vision and/or dental experiencepreferred
- At least 8 years of Supervisory experience leading people; project management experience a plus
- Demonstrated skill in managing business process optimization initiatives and projects to reduce cost, improve throughput and enhance quality outcomes
- Excellent written and verbal communication skills required
- Proficient windows-based computer skills and skill in navigation and use of MS Word, Excel, and Outlook