Director, Claims(Preferred Experience in Medicare and Must Live In New York)

CareSource • New York, NY

9d • $113,000 - $197,700

About The Position

Job Summary: This position is responsible for directing the overall functions of claims processing, including claims adjudication, provider relations, data analysis, reporting and process improvement. Provides oversight and supervision of the claims team. Essential Functions Responds to complaints in a prompt and professional manner and deploys effective service recovery strategies to resolve the issue. Escalates unresolved complaints when appropriate. Direct and coordinate the activities of claims and data entry areas including direct supervision of subordinates and the implementation of employment issues. Maintenance of a working knowledge of Management Information System and the coordination of required software enhancements for efficient claims processing. Assisting in the development and implementation of departmental policies and procedures Assurance of appropriate level of staff training Monitoring and documenting processing accuracy and productivity levels Preparing, submitting and monitoring various reports as required Oversee Medicare audit preparation, submission, and response processes, ensuring compliance with CMS regulations. Review, track, and manage Medicare audit findings, coordinating corrective action plans and validation activities. Ensure accurate Medicare coding, documentation integrity, and adherence to billing rules to minimize audit risk. Responsible for managing and responding to claim appeals, including Medicare-related appeals, ensuring timely and accurate resolution. Establishing department audit process and payment integrity Perform any other job related duties as requested. Education and Experience Associates in business or related field required Bachelor's degree preferred Equivalent years of relevant work experience may be accepted in lieu of required education Five (5) years of healthcare claims experience required Previous financial experience in MLTC preferred Three (3) years Previous leadership experience required Experience with Medicare coding standards (ICD-10, CPT, HCPCS) and Medicare audit processes required Competencies, Knowledge and Skills Advanced proficiency in Microsoft Word, Excel, and PowerPoint Data analysis and trending skills Experience in staffing and forecasting (preferred) Understanding of managed care claims operations Knowledge of coding and billing processes (CPT, ICD-9, HCPCS) Strong communication and negotiation skills Strategic and executive management abilities Supervisory and leadership experience Ability to work independently and collaboratively Attention to detail and critical thinking Familiarity with the healthcare field Technical writing and proper grammar usage Effective time management and decision-making skills Customer service orientation and proper phone etiquette Licensure and Certification Medical Coding or billing certification preferred Working Conditions General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SW2 The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

Requirements

• Associates in business or related field required
• Five (5) years of healthcare claims experience required
• Three (3) years Previous leadership experience required
• Experience with Medicare coding standards (ICD-10, CPT, HCPCS) and Medicare audit processes required
• Advanced proficiency in Microsoft Word, Excel, and PowerPoint
• Data analysis and trending skills
• Understanding of managed care claims operations
• Knowledge of coding and billing processes (CPT, ICD-9, HCPCS)
• Strong communication and negotiation skills
• Strategic and executive management abilities
• Supervisory and leadership experience
• Ability to work independently and collaboratively
• Attention to detail and critical thinking
• Familiarity with the healthcare field
• Technical writing and proper grammar usage
• Effective time management and decision-making skills
• Customer service orientation and proper phone etiquette

Nice To Haves

• Bachelor's degree preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Previous financial experience in MLTC preferred
• Experience in staffing and forecasting (preferred)
• Medical Coding or billing certification preferred

Responsibilities

• Responding to complaints and deploying service recovery strategies
• Directing activities of claims and data entry areas
• Maintaining knowledge of Management Information System and coordinating software enhancements
• Assisting in the development and implementation of departmental policies and procedures
• Ensuring appropriate staff training
• Monitoring and documenting processing accuracy and productivity levels
• Preparing, submitting, and monitoring reports
• Overseeing Medicare audit processes and ensuring compliance with CMS regulations
• Reviewing, tracking, and managing Medicare audit findings
• Ensuring accurate Medicare coding and documentation integrity
• Managing and responding to claim appeals, including Medicare-related appeals
• Establishing department audit process and payment integrity
• Performing other job-related duties as requested

Benefits

• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree
• Number of Employees: 11-50 employees