Claims Administration Director (Remote)

Vaya Health • NC

107d

About The Position

The Claims Administration Director is responsible for providing leadership and direction, policy and procedure guidance, monitoring, analysis, reconciliation, resource allocation, and coordination to the Claims Administration and Claims Encounter Management teams. This position is also responsible for overseeing the provider claims adjudication process in the Managed Care Information System (MCIS), encounter reporting to the Department, including Consumer Data Warehouse (CDW) reporting. The Claims Administration Director is responsible for working with the Claims Administration department to ensure claims adjudication quality control activities are monitored and adhered to as required by Vaya Heath (Vaya) policy. Additionally, this position will work closely with Vaya leadership across the organization, including Plan Configuration, Information Technology, Contracting, Network Provider Relations, Regulatory Affairs, and Clinical Support to meet Vaya’s strategic plans and objectives. The duties listed within pertain to both the Medicaid Direct and Tailored Plan which requires oversight for behavioral and physical health claims management.

Requirements

• Bachelor’s degree in Business Administration, Accounting, Finance, Healthcare, Human Services or related field required.
• 10 years of claims processing experience; supervisory role with increased responsibilities over time.

Nice To Haves

• Master’s degree preferred.
• Physical health claims experience within a Medicaid managed care environment is preferred.

Responsibilities

• Provides leadership and direction in order to achieve established business goals and objectives.
• Establish team goals, objectives, and operating procedures.
• Provides leadership for the Claims Administration team to ensure that all claims are processed for payment accurately and in a timely manner.
• Identifies and resolves operational issues using well defined/documented processes, expertise, and judgment.
• Ensures the Claims Administration team participates in system testing to ensure continuous operations.
• Monitors departmental processing activities to ensure that Vaya’s service, quality, productivity, service level agreements, and goals are achieved.
• Serves as Vaya’s expert in the areas of provider billing, provider reimbursement, encounter reconciliation, member and recipient eligibility, and enrollment.
• Collaborates with other Vaya business teams to develop, document, and standardize procedures and workflows to support operational improvement.
• Participate as a Subject Matter Expert (SME) on systems operations, recommend changes for system design, methods, procedures, and workflows which enhance claims operations.
• Reviews, examines, and provides leadership for the processing and handling of unusual or complex claims or eligibility issues.
• Monitors weekly/monthly reports on claims activities; provides management with updates and progress reports.
• Manages the Claims Administration team to ensure adherence to all departmental policies and procedures, HIPAA regulations, and other state and federal requirements.
• Participates in Cross-Functional Teams (CFTs) as assigned.
• Attends State meetings as needed to stay informed of changes in local, State, Federal, and Division requirements.
• Ensure adjudication rules align with contractual and other regulatory requirements.
• Performs other independent duties and projects as assigned.

Benefits

• Remote work opportunity.
• Flexible working hours.
• Open until filled application deadline.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Bachelor's degree
• Number of Employees: 501-1,000 employees