Position Summary
The Director of Claims and Fee for Service will be responsible for directing and coordinating all aspects of claims, fee for service, and encounters processes. Directly overseeing and managing the claims and fee for service departments. Works closely with the VP of TPA Operations and department heads to effectively process and pay claims from providers and facilities in a timely manner and in compliance with federal and state regulations.
Duties and Responsibilities
- ● Oversee claims processing functions of the TPA, health plan, and federal regulations and reporting.
- ● Implement and oversee Medicare/Medicaid changes (i.e., changes of CPTs/DXs, Local Coverage Claims Processing Guidelines).
- ● Audit claims report and process claims payment cycle for claims department.
- ● Work in conjunction with the VP of TPA Operations to research, review and interpret Policy and Network Guidelines.
- ● Establish and maintain policies and procedures for claims and fee for service departments.
- ● Develop claims and fee for service strategic goals and objectives.
- ● Supervise and train all managers/supervisors of the claims and fee for service department, and oversight of all the department's functions, leading the department to be able to handle a high volume of claims.
- ● Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims and encounter processing and provider inquiries (written or verbal).
- ● Collaboration and communication with other departments on claims and encounter issues, related projects, and inter-departmental operations issues.
- ● Maintain a full comprehensive understanding of the covered benefits, coding and reimbursement policies and contracts.
- ● Participate and fully cooperate in the health plan's accreditation efforts and audits.
- ● Analyze, track and trend claim and transaction data; identify any potential service or systems issues; implement interventions and determine success of intervention.
- ● Completes performance objectives, performance reviews, salary changes, and disciplinary actions on a timely basis as per Company policy. Conduct interviews for new position with claims and fee for service Supervisor/Manager.
- ● Performs other duties as required and assigned.
Knowledge
- • Bachelor’s Degree or equivalent experience
- • 5-8 years of Claims Management experience in the healthcare organization
- • Broad medical terminology, CMS and AHCA regulations and reporting
- • Experience in healthcare data management
- • Extensive knowledge in regulatory compliance for claims processing.
Skills
- • Demonstrated experience developing and lading process improvement projects that drove operations efficiencies.
- • An entrepreneurial mindset geared toward creating, executing, and continuously improving health plan operations and implementations.
Job Type: Full-time
Pay: $80,000.00 - $90,000.00 per year
Benefits:
- 401(k)
- Dental insurance
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Parental leave
- Tuition reimbursement
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Work setting:
Experience:
- Healthcare Claims Management: 5 years (Required)
Language:
Ability to Commute:
- Doral, FL 33178 (Required)
Ability to Relocate:
- Doral, FL 33178: Relocate before starting work (Required)
Work Location: In person