Martins Point Health Care, Inc

Senior Director, Claims & Payment Integrity - Remote

Martins Point Health Care, Inc • $120K — $150K *
US-AnywhereRemote in Portland, ME
Healthcare
8 - 10 years of experience
Reposted 6 days ago
Job Overview by Ladders

Qualifications

  • Bachelor's degree required; Master’s preferred.
  • CPC certification preferred.
  • 10+ years of health plan management experience required.
  • Experience managing vended system applications.
  • Experience with test plan development, strategy, and execution.

Responsibilities

  • Drive quality and timely claims processing for regulatory compliance and financial management.
  • Enhance inventory management processes and auto adjudication.
  • Optimize vendor oversight and seek new vendor opportunities through RFI/RFP.
  • Collaborate with business and IT for system readiness on claims processing impacts.
  • Ensure operational readiness, testing, and training for claims processing updates.
  • Act as business owner for claims processing vendors, managing day-to-day operations.
  • Develop and maintain claims process documentation with quality assurance controls.

Benefits

  • Opportunity to lead innovative projects impacting claims administration.
  • Access to professional development resources and training.
  • Work in a collaborative environment focusing on process optimization.
  • Engagement with cutting-edge technologies in claims processing.
  • Possibility of shaping provider payment methodologies and policies.
Full Job Description
Position Summary
The Senior Director, Claims & Payment Integrity, is responsible for oversight of health plan claims administration and payment integrity functions. The position will develop, maintain, and optimize process flows to maintain claims payment accuracy.
Job Description

Key Outcomes:
  • Drives quality, timely claims processing to allow the health plan to achieve regulatory compliance, robust financial management and product strategy outcomes
  • Oversee strong inventory management processes and enhance auto adjudication
  • Delivers strong vendor oversight to optimize system processing to improve efficiency and accuracy; pursue new vendor opportunities including Request for Information (RFI)/Request for Proposal (RFP) as deemed appropriate
  • Collaborates with business and IT teams to ensure system and operational readiness for system fixes, configuration, and project rollouts impacting claims processing
  • Ensures operational readiness, testing, training, reporting, and communications are in place for claims processing updates
  • Acts as business owner for claims processing and edit vendors, ensuring oversight of vendor, including day-to-day management, roadmap reviews and joint operating committee management
  • Oversees, develops, and maintains documentation for claims and configuration processes and procedures with appropriate controls, reporting and quality assurance
  • Develops work intake mechanisms, exploring and implementing tools to manage claims processing tickets, prioritize backlog and assess different work types (i.e., reporting, configuration, project vs. production fixes, etc.)
  • Remains up to date on industry trends and advancements in claims provider reimbursement and system technology to identify opportunities for improvement
  • Supports regular audits and quality checks to ensure data accuracy and system performance
  • Oversees the research, development, implementation, ongoing operational maintenance and administration of provider payment methodologies and fee schedules for all provider types in support of provider contractual arrangements
  • Supports the development and integration of provider payment policies and guidelines applicable to institutional and professional reimbursements and in concert with the Organization's products and member benefits
  • Maintains all institutional and professional reimbursement methodologies leveraged by the organization. This includes demonstrating deep knowledge in industry standard payment methods
  • Demonstrates working knowledge in the design and roll out of alternative payment methods that are focused on an incentive-based pay for value approach. This will require partnering cross organizationally to support the development of these new programs, and direct the operational activities necessary to stand them up
  • Researches and provides recommendations on development of new or enhancements to existing reimbursements in conjunction with corporate and contractual initiatives including sound financial modeling/impact analyses


Education/Experience:
  • Bachelor's degree required; Master's in business administration or comparable advanced degree strongly preferred
  • CPC Preferred
  • 10+ years health plan management experience required
  • Experience managing vended system applications
  • Experience with test plan development, strategy, and execution


Skills/Knowledge/Competencies (Behaviors):
  • Demonstrates an understanding of and alignment with Martin's Point Values.
  • Maintains knowledge and understanding of reimbursement agreements as well as claims and billing practices that impact cost and utilization data.
  • Detailed knowledge of applicable regulatory and accrediting body standards (National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services (CMS))
  • Develops and maintains positive, effective working relationships with colleagues, vendors, and other internal and external customers.
  • Excellent workflow and inventory management skills.
  • Excellent problem solving, quantitative and analytical skills with the ability to assess performance against metrics.
  • In-depth technical knowledge and ability to learn new technologies; knowledge of the Software Development Life Cycle (SDLC).
  • Ability to manage, organize, and prioritize workload in a timely accurate manner.
  • Ability to manage multiple competing demands and function independently.
  • Knowledge of industry standards for claims and enrollment configuration, reporting and analysis.
  • Knowledge of benefit coverage and servicing members, providers, and the DoD, CMS/ Medicare Advantage, and ME state insurance coverage.
  • Knowledge of managed care computer systems, features, and reporting.
  • Demonstrated interpersonal, communications, operational, team building, and quality improvement skills.
  • Critical thinking: can identify root causes and implement short- and long-term sustainable solutions.


There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

This position is not eligible for immigration sponsorship.

About Martins Point Health Care, Inc

Martins Point Health Care is a non-profit health care organization that provides primary care, specialty care, and health insurance plans to patients in Maine and New Hampshire. The company was founded in 1981 and is headquartered in Portland, Maine. Martins Point Health Care operates several health care centers and offers a range of services, including preventive care, chronic disease management, and behavioral health services. The company is committed to providing high-quality, affordable health care to its patients and has received numerous awards for its work in the industry.
Learn more about Martins Point Health Care, Inc
Size
800 employees
Industry
Healthcare
Founded
1981
* Ladders Estimates

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