Director, Claims Operations

SCAN Health Insurance•Long Beach, CA

1d•Remote

About The Position

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. About SCAN SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, New Mexico, Washington and Texas. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn; Facebook; and Twitter. The Job As the Director of Claims Operations, you will 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 manage a team of various specialized skill sets and disciplines.

Requirements

Bachelor’s Degree or equivalent experience
Demonstrated management experience.
Strong interpersonal skills, including excellent written and oral communication skills: strong commitment to detail.

Nice To Haves

6 to 8 years claims operations and/or systems experience with Medicare and Medicaid, including Medicare Pricing Rules and Fee Schedules, DRP, OPPS, bundling and third-party applications.
Familiar with variety of the Medicare and Medicaid concepts, practices, and procedures.
Knowledge of HIPAA transaction sets, regulations/privacy laws.

Responsibilities

Oversee and provide operational guidance to the claim’s mailroom, claim’s production, claim’s audit, provider disputes, delegated claim’s 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.
Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures.
Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.
Utilize experience and judgment to plan and accomplish goals that are intended to drive the efficient, accurate, timely, and compliant claims adjudication function.
Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; and participating in professional societies.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
Excellent 401(k) Retirement Saving Plan with employer match
Robust employee recognition program
Tuition reimbursement
A competitive compensation and benefits program;
Excellent Retirement Savings program;
A work-life balance