Director of Claims

Position: Direcotr of Claims

Location: Remote (with restrictions. must live in CA, AZ, NM, NV, or TX)

Pay: $70-80/hr (based on experience and flexible in pay)

```Overview```
We are seeking a highly skilled and experienced Director to join our team. As a Director, you will be responsible for overseeing and managing various aspects of our Medical Claims Department. This is a leadership role that requires strong organizational skills, attention to detail, and the ability to effectively communicate with team members and stakeholders.

```Job Purpose```

Direct the strategy and operation of the Claims Department to ensure that claims are adjudicated in an efficient, accurate and timely manner and in accordance with Federal and State, Regulatory, as well as Plan standards. Fulfill the Claims Department mission by conducting thorough analysis, evaluation and disposition of claims to achieve superior customer service and claim results at the most reasonable cost. Ensure customer complaints and inquiries are resolved timely and accurately. Provide guidance and develop policies related to claims operations. Oversee and manager a team of various specialized skill sets and disciplines.

```Responsibilities```

- Oversee and provide operational guidance to the claims mailroom, claims production, claims audit, provider disputes, delegated claims resolution, recovery, member balance billing and compliance oversight functions within the department.

- Provide interpretation of Benefits, Delegated Contracts, and Provider contracts in matters regarding claim functions.

- Analyze and resolve escalated and/or complex member and provider claims concerns.
- Lead activities related to internal and external audit responses. Develop and implement corrective action plans as necessary.

- Prepare reports by collecting, analyzing, and summarizing information and trends.

- Attend various committee meetings regarding regulatory requirements, compliance, member and provider issues, and strategic planning.

- Monitor claims efforts internally and externally by auditing accounts and reports and directing new approaches.

- Comply with federal and state regulations by studying existing and new regulations, legislation, and laws.

- Keep abreast of any changes to legislation and regulations which pertain to health insurance claims. Modify and/or develop internal policies and procedures to ensure operations remain in compliance.

- Resolve non-standard claims by examining claims, policies, contractual responsibilities, regulatory guidelines, and other records. Determine company’s liability, negotiate settlements, and reach agreement with claimant according to contract provisions.

- Communicate with Senior Management regarding compliance and if needed, corrective action plan reports.

- Achieve financial objectives by preparing an annual budget, approving appropriate expenditures, analyzing variances, and initiating corrective action plans to say on budget.

- Build and maintain strong teams of internal and external resources that are technically competent and characterized by a high level of coordination and trust to resolve claim matters.

```Skills```
- Proficiency in IKA or any other claims systems

- 3-5 years of experience in a Director level Claims role preferred
- Experience in a director level role in Medicare Claims
- Contract review experience

- Experience with team escalations. In this role you will be the point person for this activity
- Exceptional organizational skills with the ability to prioritize tasks effectively

If you are a motivated individual with a strong background in healthcare administration and possess the necessary skills to excel in this role, we encourage you to apply. Join our team as a Director and make a significant impact on our organization's success.

Job Types: Full-time, Contract

Pay: $70.00 - $80.00 per hour

Expected hours: No less than 40 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Vision insurance
• Work from home

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• No weekends

Work setting:

• Remote

Location:

• California (Required)

Work Location: Remote