Sr. Director, Medical Administration & Financial Management

Core Civic•Brentwood, TN

10d•$119,700 - $129,000•Onsite

About The Position

The Senior Director, Medical Administrative and Financial Management leads all aspects of the provider network, claims, and financial administration, planning, and analysis functions for Health Services through collaboration with internal CoreCivic business units, CoreCivic facilities and outside providers to ensure proper payment of healthcare claims, availability of offsite and onsite specialty providers, and effective use of non-labor medical cost financial resources. Develops and executes strategies and methodologies to deliver effective claims processing, robust and cost-effective provider networks, and adherence to non-labor medical budgets. Actively collaborates with leaders from other departments within Health Services that impact claims processing, provider networks, and medical cost to ensure overall operational effectiveness.

Requirements

Graduate from an accredited college or university with a Bachelor’s degree is required.
7+ years of experience in claims processing, provider network development, or financial management within the health insurance industry or corrections-based administrative healthcare is required, including five years of supervisory experience in healthcare cost and/or clinical data analysis and with coding systems such as HCPCS, CPT, and/or ICD is required.
Knowledge and understanding of Medicare/CMS requirements is required.
Must be organized, attentive to detail, and able to multi-task while maintaining a professional demeanor.
Strong leadership skills are a prerequisite, including excellent interpersonal, communications, problem solving and negotiating skills.
Proficiency in Microsoft Office applications required, including intermediate or advanced proficiency with Microsoft Excel.

Nice To Haves

Additional medical claims or utilization management experience may be substituted for the required education on a year-for-year basis.
Excellent analytical and decision-making skills is preferred.

Responsibilities

Oversees the day-to-day claims processes, including inventory management and claims processing, claim adjustments, recoupments, and refunds to meet internal and industry (CMS) quality and timeliness standards.
Oversees the day-to-day provider network processes, including provider contract agreements, provider relations, and expanding access to care for medical services not delivered internally by CoreCivic medical team members, and acts as an approver and signatory for provider agreements.
Develops regular and ad-hoc reporting and analysis for non-labor medical costs, manages and administrates health services budgets, and assists with the development and implementation of non-financial health services reporting as needed.
Builds a high-functioning team that meets all operating goals, including quality, efficacy and cost of health care, administrative expense, customer service, performance improvement, regulatory requirement satisfaction, and staff engagement.
Works with the executive leadership to execute the mission and goals established for the Health Services team.
Defines the direction and strategy for the Provider Network, Claims Processing, and financial management functions. Identifies gaps in systems, technology, budget, and processes for responsible teams.
Develops, manages, and maintains staffing plans to support fluctuating resident populations, driven by new business, new products, or department changes that are designed to meet or exceed the defined performance standards.
Provides mentoring, coaching, and support to direct reports to build and strengthen team effectiveness.
Provides access and direction to internal and external educational resources to aid in closing any technical gaps as they arise.
Acts as a liaison between claims, provider network, utilization management, scheduling, and offsite medical providers to ensure claims are processed accurately and timely.
Works with corporate and operations finance teams to effectively describe, monitor, and help mitigate offsite medical costs.
Develops and implements operational strategy to reduce offsite medical spend, claims inventory, reduce claims processing costs, and maximize claims compliance efforts.
Develops and directs team to meet KPI's in all areas of responsibility.
Maintains up-to-date industry knowledge related to claims processing, provider network, and financial management, including compliance requirements and claim integrity; stop loss markets, trends, and issues; payer consolidation; and other pertinent industry standards.
Develops, reviews, implements, and oversees effective administration of policies and procedures in accordance with contract compliance as well as regulatory and accreditation requirements. Including confidentiality policies, PHI and other sensitive data or information in compliance with company and regulatory guidelines.
Analyzes data and identifies trends, including effective action plan deployment, timely and effective communication upward to address areas of concern and assure prompt resolution.
Manages the periodic reporting and analysis of all health services financial functions.
Develops and reports meaningful insights to health services leadership via collection and analysis of raw data from a variety of sources, including medical record system data, medical claims data, financial systems data, as well as other sources.
Develops and implements deployment of new products, initiatives, workflows, or strategies designed to enhance the services offered to clients.
Develops action plans to facilitate needed changes for claims processing, provider network, and financial management.
Provides ongoing communication to Health Services leadership about key projects, goals, operating numbers and performance measures, challenges, and barriers to assure timely and effective issues escalation.
Assists with budget and labor resource review sessions in the annual strategic planning process, to include full ownership of strategy and initiatives for designated areas of responsibility, and development of department-level performance measures aligned with the strategic plan.
Develops and oversees financial management of designated operational department budget and company fiscal responsibility for all of Health Services.
Assists as a technical liaison between health services and information technology teams in the deployment of new or upgrading technology solutions to support the broader health services teams.
Supervises staff in the performance of their duties and evaluates as prescribed by company policy. This includes onboarding new employees, evaluating performance and preparing written performance reviews, listening to concerns and effectively resolving disputes or issues, taking corrective or disciplinary action, developing work schedules for staff and approving leave requests.
Collaborates with HR and Health Services leadership for hiring, developing, training, mentoring, and retaining high quality, productive employees.