Director, Claims Operations Jobs

The Opportunity

HealthEZ is looking for an experienced leader to join the Operations Team. The Director, Claims Operations is responsible for leading all aspects of the Claims, Plan Build, and Eligibility functions along with collaborating with other department leaders to deliver excellent service to our clients, members, and providers. This includes the development and execution of strategies and methodologies for efficient and effective claims and enrollments processing and project management for initiatives to scale our operations. The ideal candidate combines empathy and data-driven decision-making to make policy decisions, build standard processes, manage a team, and scale operations for year-over-year double-digit growth.

What you'll do

• Full ownership for the effectiveness of operating systems, policies, procedures, and staff for all claims operations.
• Manage the annual SOC 1 audit and maintain oversight of the performance of internal controls and changes to the environment throughout the year to determine if adjustments are required to internal controls to maintain an effective level of risk mitigation.
• Develop and implement operational strategy to reduce claims inventory, increase auto adjudication rate, improve quality, reduce cost of a claim, and maximize claims compliance efforts.
• Responsible for continuous quality improvement and assuring adherence to internal performance targets.
• Direct involvement with critical issues that need resolution; paying particular attention to those issues that are external facing and have impact to our clients, members, and providers.
• Responsible for working with the Chief Operating Officer on the execution of the goals established for the Claims, Plan Build, and Eligibility teams to support the Company-wide and Operations strategic objectives. Identify and define the direction of change, when necessary.
• Responsible for effectively managing confidentiality policies, PHI and other sensitive data or information in compliance with company and regulatory guidelines.
• Responsible for developing, managing, and maintaining staffing plans to support fluctuating claims and enrollments volumes, driven by new business, new products, or department changes that are designed to meet or exceed the defined performance standards.
• Responsible for proactive collaboration with other internal departments on resolution of escalated or complex issues, complaints, grievances, or risk issues.
• Utilize creative and innovative approaches in introducing new processes, technology, or tools when appropriate or evaluating existing activities.
• Act as a liaison for Operations in cross-functional initiatives and/or projects.
• Responsible for supervising staff and vendors to ensure that claims are processed accurately and timely to comply with regulatory timeframes and internal performance targets, and to ensure that individual performance goals are met while adhering to department, industry, and productivity standards.
• Proactive identification of trends and deployment of action plans with follow through to resolution.
• Oversee the day-to-day claims operational processes, including member enrollments, inventory management of claims, claim adjustments, appeals, inquiries, and new group and renewal implementations to meet quality and timeliness standards.
• Oversee and actively participate in the planning, implementation, and deployment of new products, initiatives, workflows, or strategies designed to enhance the services offered to our clients. Responsible for designing and implementing action plans to facilitate needed changes.
• Maintain up-to-date industry knowledge related to claims processing, including compliance requirements and claim integrity/fraud components, and other pertinent industry standards.
• Responsible for ongoing communication to the Chief Operating Officer about key projects, goals, challenges, and barriers to assure timely and effective issues escalation.
• Develop and continually evaluate processes, systems and explicit measurements that ensure timely and accurate execution of organizational objectives, as well as ensuring client and member satisfaction and reducing costs where possible.
• Active engagement 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.
• In collaboration with HR, responsible for hiring, developing, training, mentoring, and retaining high quality, productive employees.
• Effective communication and escalation of known risks, potential exposures, and concerns.
• Direction and monitoring of direct reports to include goal setting, definition of objectives, assignment of projects, appropriate follow-up to ensure desired progress and results, performance management, and evaluations.
• Provide monthly reporting and analysis of operating metrics and performance measures for all claims operations areas.
• Design and implement data validation controls for the enrollment and claims processing application, Virtual Benefits Administrator (VBA).
• Ensure accurate plan and benefit configuration rules are implemented and claims are processed consistently and in accordance with the terms in the Plan Documents.

What we expect from you

• 5+ years’ experience in fast-paced, transactional based environment
• Degree in business, health care, or public healthcare administration
• 5 years’ experience with leadership responsibilities in administration of self-funded TPA healthcare plans
• Certified Professional Coder preferred
• Experience with code editing rules/systems and claim integrity methodology
• Experience with stop loss management, flexible spending, and HRA/HSA administration preferred
• Experience with Virtual Benefits Administrator (VBA)
• Experience with vendor data connectivity management

Other Attributes

• Willingness to work collaboratively and creatively to offer a high level of service to clients, members, and providers
• Ability to manage multiple priorities in a fast-paced environment
• Excellent oral and written communication skills
• Ability to work independently and collaboratively
• Exceptional customer service and interpersonal skills
• Strong analytical skills
• Proficiency using Microsoft programs (Word, Excel, PowerPoint)
• Ability to think strategically with appropriate level of detail analysis to plan and execute
• Proven ability to exhibit a proactive approach to seeking solutions
• Strong organizational, self-motivation, and decision-making skills
• Effective problem-solving and influencing skills

About Us:

HealthEZ has been a leader in third party administration of self-funded health plans for almost forty years, offering a full suite of customizable plan products and services. Simplification of the member experience and compassionate service have been the backbone of our company mission from day one. Recent private equity investment and accelerating growth make HealthEZ an exciting place to work with ample opportunity for professional growth!

What We Offer you:

HealthEZ provides an excellent salary, full benefits, incentive bonuses, and additional perks. Benefits include health care, dental plan, Health Savings Account, company paid STD/LTD/Life, and 401(k) plan with employer match.

HealthEZ is an Equal Opportunity Employer