Director, Claims Operations - PHH

WVU Medicine

About The Position

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. Come join West Virginia’s fastest growing health plan at Peak Health as Director, Claims Operations. This role will be responsible for the people, process and business requirements necessary to adjudicate claims in a timely and accurate manner. Reporting to the Health Plan Executive Leadership, The Director, Claims Operations, will be an integral member of the health plan’s senior leadership team. Responsible for the design, build and day-to-day management of the Claims Department and Mailroom. Successful candidates in this role must provide strong leadership and directives that will clearly articulate department objectives and manage complex timelines. Predicts daily workflow issues and resolves issues with staff and systems resulting in meeting organization objectives, client performance guarantees and key operational and quality metrics. Additionally, as the health plan ramps up, the Director will play a direct role in the evaluation of technology and vendor relationships which will be critical to the long-term success of the plan. Expected to partner with IT and other health plan leadership to manage core administration configuration and testing from development through user acceptance as well as other technologies as applicable.

Requirements

Bachelor’s degree in Business Administration, Healthcare Administration or a related field AND Ten (10) years of experience working in Claims Operations or Healthcare Environments.
Associate’s degree in Business Administration, Healthcare Administration, or related field AND Twelve (12) years of experience working in Claims Operations or Healthcare Environments.
Four (4) years of management experience in Claims Operations, including recent experience managing people, process and technology to achieve desired operational outcomes.
Excellent written and oral communication.
Problem solving capabilities to drive improved efficiencies and customer satisfaction.
Attention to detail.
Proficiency with Microsoft Office.
Technical and operational competency to support the implementation and refinement of core administration platform.

Nice To Haves

Epic Tapestry.
Medicare and/or Medicaid Claims Operations.
Experience working in a start-up business environment.

Responsibilities

Participates in business planning and strategy sessions to improve health plan design and develop business requirements to support system implementation.
Develops and manages a staffing plan and budget for Claims Department.
Hires and manages an engaged workforce to deliver exceptional customer service and quality.
Sets team direction, resolves issues and provides mentoring and guidance to team.
Lead initiatives to improve claims processing efficiency and accuracy, reducing operational costs and improving member satisfaction.
Ensure compliance with all regulatory requirements and payer policies across claims operations.
Design and operationalize KPI and performance management frameworks to monitor claims health and support executive decision-making.
Partner with Technology teams to shape claims platform configuration and optimization.
Develop, implement, and monitor process improvement initiatives across claims and provider operations.
Deep understanding of claims lifecycle, EDI transactions, payment integrity, provider data, appeals/grievances, and audit/compliance (CMS, HIPAA, NCQA, state regs).