Director, Claims

SF Health Plan • San Francisco, CA

3d • $150,000 - $183,000 • Hybrid

About The Position

Reporting to the Operations Officer, the Director, Claims, provides strategic management. This involves collaboratively leading the ongoing operations of the Claims Department at SFHP. The Director's responsibilities also include ensuring financial integrity and exemplary service, and achieving established goals and objectives. You will also maintain internal communications to promote SFHP's mission. They support SFHP's core purpose and work to maintain a team environment. In this environment, staff can be effective, satisfied, and provide quality service to all customers, both internal and external. Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office. Salary: $150,000 - $183,000 per year

Requirements

• A bachelor's degree in health care administration, business, or a related field or equivalent experience.
• Eight to ten years of claims operations experience in a managed care environment, which included some experience with the Medi-Cal Program and six years of management-level experience
• Knowledge of Medicare, Medi-Cal, and managed care regulations
• Experience with healthcare regulatory processes and compliance audits
• Experience managing, coaching and developing staff, promoting teamwork and encouraging innovation
• Process and /or Continuous improvement training

Nice To Haves

• Master's degree preferred
• Certification in coaching and performance management preferred

Responsibilities

• Plan and manage Claims and Quality Assurance.
• Manage, coach, and inform the department managers and /or supervisors of information and tools needed to be successful.
• Lead the development of achievable, relevant departmental goals, and metrics, and continually motivate staff with them to support high individual and department performance.
• Ensure internal review and audit by QA of important operational processes in Claims including end to end claims processing.
• Chair monthly QA results review meetings with business stakeholders (Claims Manager or other managers as applicable), capacity planning, recommending, and implementing standards for and making improvements on Claims and QA operations.
• Preserve integrity of audit findings to ensure KPI measures on claims quality are accurate and champion compliance with all SFHP guidelines and regulatory standards.
• Monitor department metrics, trends, and takes action to support goal achievement.
• Provide leadership, facilitate meetings, and partner with stakeholders in the resolution of issues.
• Determine staffing needs, set short-term goals, and resolve staffing issues.
• Direct the improvement of business processes and accuracy of documentation of policies and procedures.
• Drive opportunities for automating functions.
• Champion excellent customer service throughout the organization.
• Improve inter-departmental collaboration, communication, and teamwork.
• Take on escalated issues with delegated groups or providers, and members.
• Oversee Key Performance Indicators (KPIs) for the department and support the team in achieving them.
• Manage resource capacity and team allocation to service requests, projects, organizational work groups, and ad hoc assignments.
• Develop and maintain relationships and effective communication with all levels of staff to facilitate efficient issue identification and resolution.
• Provide leadership and business expertise on assigned projects and processes.
• Ensure the department staff is informed of organization-wide information and decisions.
• Work with direct reports and teams to identify critical issues and trends, make recommendations, and provide information and recommendations to executive management; alert executive management to issues that impact the organization.
• Prepare budget, manage expenses for the Claims Department.
• Partner with Business Solutions and ITS to identify critical issues and trends, make recommendations, and provide information and recommendations to executive management; alert executive management to issues that impact the organization.
• Collaborate with EPMO to ensure that work and projects are completed in a timely, cost-effective manner, and take corrective actions.
• Ensure the appropriate reporting on a monthly, quarterly, and annual basis; assist with company financial planning and budget management functions.
• Represent Claims with internal and external stakeholders.
• Oversee department participation in all regulatory and financial audits, including resolution of audit findings.
• Participate and engage with peers at Local Health Plans of California (LHPC) to promote knowledge sharing and identify opportunities to drive best practices at SFHP.
• Provide updates to leadership and exercise good judgement to determine when escalations are necessary.

Benefits

• Health Benefits
• Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
• Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
• Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 101-250 employees