Dir Configuration, Benefit Administration

HealthFirst•New York, NY

1d•Hybrid

About The Position

The Director of Configuration, Benefit Administration is responsible for the design, implementation, and deployment of benefit configuration structures to support product and regulatory needs. This role implements the configuration structure within Healthfirst’s technology platforms to administer benefits, coordinating with Provider Contracting, Claims Operations, Provider Data Management, Clinical Operations, Payment Integrity, and Information Technology. The Director leads forums and meetings with leadership across the enterprise to develop effective and efficient benefit configuration solutions that meet business needs and objectives, maintaining alignment with claims payment. The Director analyzes complex configuration defects and recommends strategies for successful and timely remediation. The Director leads a team of managers and analysts to ensure accurate, complete, and timely configuration of benefit structures and maintenance of existing structures. The Director oversees team performance, configuration production, and quality metrics to ensure project and department goals are met. The Director also collaborates with other configuration teams to ensure all required configuration aspects are accounted for in the planning and implementation of benefit administration configuration structures. This role is critical to the success and growth of Healthfirst membership through product evolution and adherence to regulatory compliance. The objective of this role is to ensure that the benefit structure implementation delivers the intended experience through claim adjudication, including benefits, authorizations, reference data, claims editing, regulatory requirements, payment policies, and overall claim system functionality. The Director serves as the authoritative source for benefit design, product implementation, and regulatory rule adherence within benefit and product. Recognized as an influential leader, the individual at this level functions as a cultural ambassador and strategy driver for Healthfirst. He/she promotes and reinforces behavior consistent with Healthfirst’s desired culture and fulfills his/her role in aligning Healthfirst’s strategic initiatives with desired organizational outcomes. This position requires three days per week in office (Tues/Wed/Thurs) at 100 Church Street, NYC.

Requirements

Bachelor's Degree from an accredited institution or equivalent work experience
HS Diploma or GED of accredited institution
Proven ability to develop strong interpersonal relationships, as a leader and team member with experience communicating and influencing impact and progress to senior leadership level
Successful track record developing creative, workable strategies and tactics to accomplish division, corporate and plan goals

Nice To Haves

Master's degree or MBA from an accredited institution
Healthedge Configuration and Integration experience
Proven experience in health insurance focused on claim configuration and reimbursement processes
Proficiency in provider contract reimbursement terms and code sets (HCPCS, ICD10, DRGs, CPT, etc.), and claims processing practices
Knowledge of medical claims and adjudication procedures, including the application of reimbursement and medical policy guidelines and contract pricing
Knowledge of benefit administration and or claim payment methodologies and regulatory frameworks governing health plan reimbursement methods in Medicare, Medicaid and commercial insurance markets
Experience leading complex, technical, cross-functional programs and working with senior executives
Experience articulating complex issues to audiences with varying levels of technical expertise
Experience influencing leaders, breaking down barriers and managing competing priorities
Strong problem solving and analytical skills

Responsibilities

Develop and implement comprehensive operational strategies aimed at improving efficiency, productivity, and quality
Lead initiatives to identify inefficiencies in current processes and procedures, recommending and implementing solutions to optimize workflows
Identify opportunities for cost reduction and resource optimization while maintaining or improving service delivery and quality
Work closely with department heads, project managers, and other stakeholders to align operational goals with organizational objectives.
Facilitate collaboration to drive consistent improvement across the organization
Support change management efforts related to operational improvement initiatives, ensuring successful implementation and adoption of new processes and technologies
Identify potential operational risks and develop mitigation strategies to minimize disruptions and ensure smooth operations
Drive flexible, repeatable and scalable benefit configuration design and implementation processes with industry best-practices
Engage directly with other operational teams and leaders to provide input on the scope, approach, and timing of configuration work
Assess upstream and downstream impact of configuration and policy changes to proactively identify and mitigate risk
Manage interdependencies across other configuration units and business areas to ensure delivery timelines and project deadlines are met
Identify and resolve inconsistencies between system configurations, regulation, contracts, and policies
Maintain effective and consistent configuration testing protocols and quality controls
Manage and monitor team performance, production and quality
Establish structure for ongoing education, training and knowledge share across team
Prepare and present updates to the business and senior executives on benefit configuration strategies, activities, and metrics
Lead and support company-wide initiatives
Work with internal and external parties to ensure benefit administration logic and business rules are well understood and administered appropriately
Actively support all Compliance and Regulatory requirements with appropriate policies, processes, reports, and audit support.
Additional duties as assigned.