Director, Claims

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

The Health Planof San Joaquin is now hiring an experienced and dedicated Director, Claims
!

Location: We are looking for someone who lives in our service area. (Must reside in California.)

Remote: This is a remote position; however, must be able to attend quarterly onsite meetings, and as needed for business and community purposes.

What You Will Be Doing: Under limited supervision, the Director of Claims is responsible for developing and overseeing the implementation of strategic and operational objectives and plans consistent with internal and external requirements, best practices, and HPSJ strategies and objectives. Work is varied and complex and requires a high degree of discretion and independent judgment.

Claims Managers

Claims Analyst

Our Vision: Continuously improve the health of our community.

Our Mission: We provide healthcare value and advance wellness through community partnerships.

Essential Functions:

• Identifies, develops, plans and executes business strategies, collaborating with executives, peers and others to ensure effective integration; directs the development and implementation of department goals and actions plans
• Oversee routine and ad hoc internal and external audits and direct the development, implementation and monitoring of corrective action plans
• Develops and monitors quantitative and qualitative analyses of claims data, trends and forecasting; implements appropriate interventions
• Oversees preparation for and participate in regulatory audits and external review activities; develops and monitors corrective actions plans
• Develops or directs the development of policies; ensures the development and implementation of appropriate companion procedures, guidelines and other documents.
• Proactively Identifies and develops strategies to address issues and trends with claims processing
• Ensure compliance with applicable laws and regulations
• Oversee the development, implementation and maintenance of the appropriate and required data, records, reports and other documentation
• Identifies and oversees the implementation of process improvement strategies
• Leads the development, implementation and maintenance of best practice methodology, including metrics; ensures dissemination and understanding among stakeholders
• Anticipates technology needs; oversees development and implementation; collaborates to improve or upgrade current technology solutions
• Develops and manages department budget, implements appropriate interventions
• Promote and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ's strategy, vision, mission and values
• Hires, develops and retains, and ensures that subordinate managers hire, develop and retain an adequate and competent staff

Non
- Essential Functions:

• Other duties as required.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• Expert knowledge of and ability to apply and facilitate the adoption of best practices.
• In-depth knowledge of the principles and practices of claims operations.
• In-depth knowledge of health plan functions and interactions and their impact on claims.
• In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs as they relate to claims.
• In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions, and industry standard payment practices.
• In-depth knowledge of claims processing systems.
• Financial acumen:
  Interprets and applies understanding of key financial indicators to make better business decisions.
• Manages complexity:
  Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
• Decision quality:
  Makes good and timely decisions that keep the organization moving forward.
• Strategic mindset:
  Sees ahead to future possibilities and translates them into breakthrough strategies.
• Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.
• Ability to create relevant department objectives, and create, execute and monitor business plans.
• In-depth knowledge of internal and external audit processes, and the ability to effectively implement and maintain them.
• Demonstrated ability to develop and manage realistic budgets.
• Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals inside and outside of the HPSJ.
• Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of HPSJ
• Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, and maintain effective, high-performance teams.
• Strong assessment and…