Director, Claims

SAN JOAQUIN COUNTY HEALTH COMMISSION•Modesto, CA

2d•Remote

About The Position

Under limited supervision, the Director of Claims is responsible for developing and overseeing the implementation of strategic and operational objectives and plans consistent with internal and external requirements, best practices, and HPSJ strategies and objectives. Work is varied and complex and requires a high degree of discretion and independent judgment.

Requirements

Expert knowledge of and ability to apply and facilitate the adoption of best practices.
In-depth knowledge of the principles and practices of claims operations.
In-depth knowledge of health plan functions and interactions and their impact on claims.
In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs as they relate to claims.
In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions, and industry standard payment practices.
In-depth knowledge of claims processing systems.
Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.
Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
Decision quality: Makes good and timely decisions that keep the organization moving forward.
Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.
Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.
Ability to create relevant department objectives, and create, execute and monitor business plans.
In-depth knowledge of internal and external audit processes, and the ability to effectively implement and maintain them.
Demonstrated ability to develop and manage realistic budgets.
Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals inside and outside of the HPSJ.
Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of HPSJ
Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, and maintain effective, high-performance teams.
Strong assessment and analytical skills, including the ability to synthesize, distill concepts, draw conclusions and identify implications.
Build networks: Effectively build formal and informal relationship networks inside and outside of the organization.
Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.
Persuades: Uses compelling arguments to gain the support and commitment of others.
Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
Ensures accountability: Holds self and others accountable to meet commitments.
Drives results: Consistently achieve results, even under tough circumstances.
Strong project management skills, including the ability to manage organizational-wide projects to successful conclusions.
Manages ambiguity: Operates effectively, even when things are not certain, or the way forward is not clear.
Strong knowledge of change management theory, with ability to anticipate and implement effectively.
Strong customer service skills.
Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.
Ability to supervise staff in a manner that maximizes employee performance and business results, which includes very strong coaching/counseling skills and ability to function as a mentor.
Ability to speak and be understood in English.
Ability to handle confidential information with appropriate discretion.
Bachelor’s Degree or related fields or equivalent experience; and
At least four years as a manager in a health plan overseeing all aspects of claims administration; and
At least six years Medi-Cal claims experience; and
Supervisory experience in a healthcare setting.
Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

Nice To Haves

In-depth knowledge of QNXT core processing system.
Master’s degree.

Responsibilities

Identifies, develops, plans and executes business strategies, collaborating with executives, peers and others to ensure effective integration; directs the development and implementation of department goals and actions plans
Oversee routine and ad hoc internal and external audits and direct the development, implementation and monitoring of corrective action plans
Develops and monitors quantitative and qualitative analyses of claims data, trends and forecasting; implements appropriate interventions
Oversees preparation for and participate in regulatory audits and external review activities; develops and monitors corrective actions plans
Develops or directs the development of policies; ensures the development and implementation of appropriate companion procedures, guidelines and other documents.
Proactively Identifies and develops strategies to address issues and trends with claims processing
Ensure compliance with applicable laws and regulations
Oversee the development, implementation and maintenance of the appropriate and required data, records, reports and other documentation
Identifies and oversees the implementation of process improvement strategies
Leads the development, implementation and maintenance of best practice methodology, including metrics; ensures dissemination and understanding among stakeholders
Anticipates technology needs; oversees development and implementation; collaborates to improve or upgrade current technology solutions
Develops and manages department budget, implements appropriate interventions
Promote and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values
Hires, develops and retains, and ensures that subordinate managers hire, develop and retain an adequate and competent staff
Other duties as required.

Benefits

Competitive salary
Robust and affordable health/dental/vision with choices in providers
Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
Two flexible spending accounts (FSAs)
Employer-Paid Term Life and AD&D Insurance
Employer-Paid Disability Insurance
Employer-Paid Life Assistance Program
Health Advocacy
Supplemental medical, legal, identity theft protection
Access to exclusive discount mall
Education and training reimbursement in addition to employer-paid elective learning courses.
A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.