The Director, Claims Production provides strategic and operational leadership and direction in the development, implementation and on-going support of claims for the medical group and IPA. This position will engage and collaborate with key partners on methods and best practices of identifying and improving operational efficiencies in claims and act as the point of accountability for delivering large scale, complex, and cross-organizational projects and/or program strategy deliverables on time and on budget. The Director, Claims Production plans, supports, evaluates and oversees key aspects of the strategic, operational and financial business plan Claims in collaboration with the Executive Management Team and is responsible for supporting a sound infrastructure and policies and procedures consistent with these objectives.
Principle Duties & Responsibilities
Provides leadership with respect to strategic planning, financial management, service development and special projects, designs viable strategies for claims. Conducts financial analysis/projections, creates business plans and ROIs as required to support strategic planning.
Directs the daily activities of external and internal team members to design and develop approaches to projects and/or program strategies as they are implemented, ensuring that strategic direction is in line MCMF objectives. Provides support and business acumen to assist the Executive Director of Claims and Chief Financial Officer.
Assumes primary responsibility for the planning, coordination and logistics of key meetings. Develops meeting structure, presentation, agenda, and handouts for designated group operational meetings.
Develop and maintain audit process to assist with claims processing error detection and correction. Works with other managers to create a fluid process to deal with Physician claims adjustments.
Create, manage and develop with others various standard reports that support the claims management and customer service process including but not limited to claims timeliness, days on hand, claims inventory, adjustment tracking.
Works closely with internal and external parties to direct, organize, and facilitate high visibility projects which focus on the customer’s overall experience. Ensures that customer experience is considered in critical enterprise initiatives by overseeing the integration of patient experience in all MCMF initiatives.
Develops positive working relationships and effectively interfaces with physicians, MemorialCare Hospitals and Ancillary Providers to communicate relevant issues, resolve conflicts and address contractual issues as required. Participates in periodic meetings with each physician group to ensure adequate communication and information dissemination.
Provides leadership and support in the successful implementation of programs which align with the strategic goals and growth objectives for MCMF.
Monitors performance related to claims via claims and financial reports and analysis, statistical data and patient satisfaction surveys. Participates in outreach as necessary.
Keeps abreast of relevant economic, industry and legislative issues affecting physician practices including participation in applicable professional associations and communicates any relevant issues to key stakeholders as appropriate.
Knowledge of claims management software, MS Word, Excel, Access
Understanding of Coordination of Benefits and Medicare claims processing.
Understanding of medical terminology and familiarity with managed care compensation models.
Knowledge of appropriate claims diagnosis and procedure coding.
Evidence of leadership, creativity, integrity, initiative, and problem solving.
Evidence of the ability to plan, execute and evaluate change.
5 years of experience in a progressive healthcare organization with an emphasis on management of independent physician associations or medical groups.
Experience or knowledge in managed care claims processing and customer service.
Strong interpersonal, written, verbal and presentation skills.
Strong fiscal management
Ability to problem solve operational and regulatory issues
Ability to motivate and lead team of highly educated and skilled direct reports.
Ability to use the necessary software systems needed to evaluated data, write memos, etc.
Demonstrates proficiency in budgets, data analytics, staffing and development, partnership/client collaboration, ROI analysis and projections.
Demonstrated ability to build and/or enhance strong teams with trust, respect, inclusiveness and open communication regarding program issues and results.
Demonstrates responsibility, accountability, discretion and sound judgment. Organizes workload to provide reliable follow-through and accountability to deadlines / timelines
B.S. degree in a healthcare field. Master’s degree strongly preferred.