Director Process Improvement

Overview

Become a part of our caring community and help us put health first The Director, Process Improvement provides direction and management to the claims processing vendor for claims reimbursements and operational activities to provide superior service to internal and external customers in support of the VA Community Care Network. The Director, Process Improvement coordinates with the Director, VA CCN Claims Oversight for alignment of accurate claims processing.

Ensures a high level of quality in all areas while meeting or exceeding performance goals.

This position is created specifically to assist with Humana’s efforts to secure and, if awarded, transition into a new business opportunity. Please note that continued employment in this role is expressly contingent upon Humana’s receipt of the business opportunity and a satisfactory transition into the work. In the event Humana does not pursue the opportunity or determines that a timely and satisfactory transition cannot be achieved, employment may be subject to termination.

The Director of Claims Oversight will lead a dedicated team responsible to establish and maintain comprehensive oversight of the VA CCN payment invoicing process with a focus on vendor management and payment integrity. This role ensures timely reconciliation of VA payments, effective management of accounts receivable and recoupments, administration and oversight of X12 processes and files as well as coordination of banking and reporting activities.

The Director will serve as a key liaison between internal stakeholders and claims vendors to optimize operational efficiency and compliance with regulatory standards.

• Oversee claims processing activities performed by external vendors, ensuring accuracy, timeliness, and compliance with contractual and regulatory requirements.

• Monitor and review claims payment processes, identifying opportunities for process improvement and risk mitigation.

• Direct the reconciliation of claims payments, maintaining detailed records and ensuring resolution of discrepancies.

• Manage accounts receivable and recoupment processes, coordinating with finance and provider relations teams to ensure timely recovery and reporting.

• Lead banking coordination and reporting activities, working closely with finance to maintain transparency and accuracy in financial transactions related to claims.

Use your skills to make an impact

• Our Department of Defense contract requires U.S. Citizenship for this role

• Must successfully receive interim approval for government security clearance (NBIS
  - National Background Investigation Services)

• HGB is not authorized to do work in Puerto Rico per our government contract.
  
  We are not able to hire candidates that are currently living in Puerto Rico.

• Bachelor's degree in Accounting, Finance, Business, Health Care Administration, Government Contract Management, or Operations Management or if non-degree, must have at least 5 years of experience with TRICARE and/or VA CCN in claims or financial transaction area.

• 5 years of experience in a managed care environment and financial transactions and claims area

• Experience with VA, TRICARE contracts and/or the military health care delivery system, and/or Medicare reimbursement

• Experience with data analysis and making decisions using data

To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

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