Director - Claims - Healthplan

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Location Address: 9521 San Mateo NE, Albuquerque, New Mexico , United States of America

The Director provides strategic leadership, fiscal accountability and operational excellence for the Presbyterian Health Plan Claims Operations and Encounter Resolution teams. Responsible for directing the operations of the Claims Department for Commercial/ASO, Medicare and Medicaid products, to ensure that all functions related to claims receipt, processing and payment are performed within the established quality and quantity standards. Lead the encounters resolution team and be leader responsible for encounters completeness and facilitating maximized Medicaid rate setting.

This leadership role is accountable to drive execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market‑leading practices. In addition to operational, this leadership role is accountable to champion and execute on the prioritized deployment of Auto‑Adjudication methodologies, use of Robotic Process Automation (RPA/Bots), increased first pass and overall encounter acceptance and process simplification to achieve operational optimization and cost effectiveness.

Role will lead department strategic objectives and have responsibility to achieve measurable gains in reduced cycle times and improve functional effectiveness in departmental processes. This role will make use of deep claims and encounters expertise to improve the member and provider experience.

The Director of Claims and Encounters provides strategic leadership, fiscal accountability and operational excellence for the Presbyterian Health Plan (PHP) Claims Operations and Encounter Resolution teams. This leader is responsible for directing the operations of the Claims Department for Commercial
/ASO,
Medicare and Medicaid products, to ensure that all functions related to claims receipt, processing and payment are performed within the established quality and quantity standards. You will lead the encounters resolution team and be the leader responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role is accountable to drive execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market‑leading practices.

In addition to operational, this leadership role is accountable to champion and execute on the prioritized deployment of Auto‑Adjudication methodologies
, use of Robotic Process Automation (RPA/Bots), increased first pass and overall encounter acceptance and process simplification to achieve operational optimization and cost effectiveness. This role will lead department strategic objectives and have responsibility to achieve measurable gains in reduced cycle times and improve functional effectiveness in departmental processes. This role will make use of deep claims and encounters expertise to improve the member and provider experience.

• Accountable for leadership of department managers and supervisors with responsibility for workforce planning, implementing process improvement initiatives and staff development.
• Leads and partners with business and technical subject‑matter experts on operational and transformational initiatives, in an agile manner, to enhance automation, innovation, process improvements, and maximize efficiencies across the continuum.
• Effectively translates strategic goals into specific operating and resource plans.
• Establishes and maintains key claims and encounters KPIs to demonstrate operational performance.
• Drives continuous improvement activities in standard process, adjustor behaviors and claims outcomes.
• Maintains market‑leading claims and encounters quality assurance and testing center of excellence.
• Monitors department’s budget and is responsible for monthly variance reporting.
• Ensures regulatory compliance across all areas of accountability, while delivering innovative and creative solutions that improve member experience.
• Drives contract NM Medicaid…