Director of Operations – Claims Administration

To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by translating business strategy into an actionable business plan\: Responsible for creating the business plan to carry out divisional goals and strategy. Influence/provide input to Senior Leadership regarding the feasibility of business vision and goals. Conducts risk assessments and devises actionable steps to mitigate risks. Works with Service Organization and Configuration Leadership to determine the best strategy to achieve vision and goals. Creates a business plan with functional/project managers. Sets measurable expectations and deliverables. Develop a culture that fosters sustained high performance and customer focus.

Primary Accountabilities Assemble and prepare staff to operationalize strategy\: Assembles resources with the right knowledge, skills and experience to achieve results. Communicates and clarifies expectations, timeframes and deliverables. Provide the leadership and development growth of staff through planned development and coaching. Ensures that a steady pool of talent is available to meet current and future needs Translate business strategy into an actionable business plan\: Responsible for creating the business plan to carry out divisional goals and strategy. Influence/provides input to Senior Leadership regarding the feasibility of business vision and goals. Conducts risk assessments and devises actionable steps to mitigate risks. Works with Service Organization Leadership, Configuration to determine the best strategy to achieve vision and goals. Creates a business plan with functional/project managers. Sets measurable expectations and deliverables. Responsible for business oversight with maintenance of BPO applications and processes including upgrades. Establish and monitor BPO activities through Quality Assurance monitoring, testing, and data audits. Tracks laws and regulations applicable to the Operations Section and ensures compliance with those regulations. Follow all guidelines such as those related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI). Ability to interpret and adapt to changing legislative requirements ie. Affordable Care Act to include CMS and HHS bulletins and guidance. Accountable for the administrative management duties required of a management role. These activities include but are not limited to; budgeting/financial management, inventory control, hiring/staff planning and role clarification, performance planning and performance assessment, appraisals and coaching progressive discipline, termination, formal staff development and succession planning, staff salary management, reward and recognition, maintaining salary equity of individuals assigned to roles within area of accountability and between divisions having similar roles Direct the collecting and reporting of Third Party Liability Claims. Oversee the management of Coordination of Benefits. Oversee Service Level Agreements (SLAs) and communicate to operational areas outcomes. Lead the effort to conduct rigorous monthly operating reviews detailed and focused on negative variances and their corrective action plans. Analyze and make recommendations regarding appropriate management of medical claim expense including processing accuracy, system edits and network pricing opportunities. Direct the preparation of health plan operating expenses and capital budgets. Interface with management in all functional areas to develop individual department budgets, and articulate and communicate annual budgetary guidance. Approve and administer these budgets and report regularly on budget status.

Qualification:
BS in Accounting, Business, Health Care or related field or equivalent 5 plus years direct management experience in managed care organization, with proven leadership skills and business acumen, ability to lead and operate at the “macro” level Advanced knowledge with operational, financial, quality assurance, and human resource procedures and regulations. Strong leadership skills to include organizational skills, decision-making, personnel direction and project management. Knowledge of Medicare and managed care contracts desirable. Knowledge of all core business areas of Health Plans – Claims, Enrollment, Billing, UM, Configuration, IS Excellent communication and presentation skills. A solid understanding of information technology. Management problem solving and process analysis/improvement skills and experience *Comprehensive financial and analytical skills. Effective time management and organizational skills. Strong collaborative and interpersonal skills, demonstrated ability to guide and influence in a matrix environment. Direct experience with management of claims and contact processes and business practices, including detailed knowledge and management of claims and contact processes and business rules Creating excellent work environment/great place to work through employee engagement in strengthening employees’ relationship with management, with other employees and with their job. Track record of specific actions and results in identifying and responding to customer needs to create a positive customer experience Experience with a structured continuous improvement problem solving methodology Experience with strategy development, execution planning and management of high priority/high visibility information related corporate efforts Demonstrate understanding of the dependencies and linkages of major business processes, products, systems, networks, etc. and can articulate the overall vision & mission of an organization and its supporting strategies and objectives.