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Claims Director, Santa Barbara, CA


Organization: CenCal Health
Category: Director
Location: Santa Barbara, CA
Date Job Posted: January 31, 2020
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Claims Director

Director CLAIM01248
Posted: January 30, 2020
Full-Time
Santa Barbara, CA, USA

Job Details

Description

  • Provide leadership to the Claims Department staff and establish objectives which ensure that the department goals and objectives are met Supervise directly reporting staff
  • Oversee the interpretation and implementation of State and Federal statutes, regulations and mandates (including NCQA, HEDIS, HIPAA, Knox Keene, DHCS, DMHC,) pertinent to claims processing function, while improving claims processes to yield operational efficiencies
  • Ensure the timely, accurate configuration of the claims sub-system and maintenance of claims coding databases; implement benefit, provider payment rate updates, and dispute/appeal handling directives from regulatory agencies and Administration
  • Create updated Department policies and procedures as necessary
  • Ensure the efficient, timely, and accurate adjudication of claims; by maintain an adequate level of trained staff; revising operating workflows, and other necessary changes to effectively implement changing CenCal Health policies and objectives
  • Develop, implement, and monitor programs and procedures to assure the efficient and timely submission of accurate encounter data to the State
  • Manage the volume and financial impact of pended claims, and status of subsystems maintained by Claims staff
  • Ensure staff is advised of all procedural changes in a timely manner, and that such changes are implemented promptly and effectively
  • Oversee the claims service functions and claims mailroom to ensure that responses to provider inquiries, disputes or appeals, and internal inquiries are resolved accurately, promptly and with a high level of customer service
  • Provide individual and group training for hospitals and other providers on the claims process in coordination with the Provider Services Department
  • Implement any policy changes passed by the Board of Directors and/or as directed by Administration which relate to claims processing or service
  • Provide monthly Board report and statistics related to claims adjudication or service activities; ensure accuracy of statistical data submitted to Administration
  • Collaborate with Compliance, Legal, IT, Provider Services, Health Services, and other necessary departments to ensure that the claims payment system is configured and maintained appropriately to support accurate claims processing and adhere to state and federal regulatory requirements
  • Manage vendors used to support claims processing and auditing including, but not limited to, reviewing and modifying contracts, establishing and managing performance expectations, periodically surveying market for alternative vendors and participate in due diligence and annual delegation audits
  • Ensure timely recruitment, retention, training and development of qualified claims staff;
  • Drive operational innovation and support business expansion and product diversification in support of the CenCal strategic plan
  • Determine what environment and culture will create the best workplace experience for department employees
  • Ensure that department employees have a clear vision of what each team needs to achieve and that all teams and aligned and committed to department-wide success
  • Other duties as assigned

Qualifications

Skills

Required

  • Microsoft Office - Some Knowledge

Education

Required

  • Bachelors or better in Health Administration or related field.

Experience

Required

  • Knowledge of managed care contracting methods, health plan core transaction systems NCQA accreditation and HIPAA complain claim coding guidelines
  • 4 years: Recent management experience in medical claims operations or equivalent combination of education, training and experience. HMO, Medi-Cal and Medicare claims operations experience is highly desirable.
  • 5 years: Management level experience as a department Director or equivalent in a healthcare environment

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