Claims Director

TriOptus; Denver (CO); On-site; USD 103,000 - 135,000; Full time

Job summary

Explore an exciting opportunity as a Director of Claims Management with a leading healthcare provider in Denver. This role entails overseeing claims services and ensuring compliance with regulatory guidelines while managing a team. Ideal candidates will have extensive experience in healthcare claims processing and a strong educational background. Enjoy a comprehensive benefits package as you empower seniors to live independently through innovative healthcare solutions.

Benefits

401(k)

Medical insurance

Disability insurance

Paid maternity leave

Paid paternity leave

Child care support

Qualifications

• Minimum of 10 years in healthcare claims processing or equivalent.
• Strong management skills with 2+ years supervising staff.
• Current knowledge of co-pays, deductibles, and other insurance matters.

Responsibilities

• Oversee staff and claims service delivery processes.
• Ensure timely adjudication and payment of claims.
• Establish key performance indicators for department functions.

Skills

Leadership

Data Analysis

Customer Service

Education

Bachelor’s degree in accounting or related field

Tools

Microsoft Office Suite

Job description

1 day ago Be among the first 25 applicants

This range is provided by TriOptus. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$103,300.00/yr - $134,400.00/yr

Direct message the job poster from TriOptus

Empowering Client Success | Associate Director – Service & Delivery | Talent Strategy | TriOptus

Director of Claims Management

Responsibilities

• Under the supervision of the VP of Operational Accounting, the Director, Claims is responsible for ensuring the delivery of timely and efficient claims service through the daily supervision of staff. This position provides technical guidance to staff regarding investigations, adjustments, complex claims, and review and implementation of workflow to individuals based on job type.

Essential Functions and Work Responsibilities

Functional Category: Claim Management

Estimated Percent of time Spent – 80%

• Maintain a working knowledge of all regulatory and compliance guidelines that affect the scope of the department
• Responsible for the management and oversight of departmental functions such as claims adjudications, appeals, correspondence, claims adjustments, and claims support.
• Establish measures and processes by which to collect, monitor, evaluate, and report on key performance indicators
• Oversee staff and direct workflow to ensure claims are adjudicated within proper timeframes and payment of claims is executed in an efficient and timely manner.
• Ensure claims are paid correctly and promptly by performing verification of contracts and utilizing claims software.
• Ensures appeals are correctly paid and recorded in claims software.
• Communicate and update management regarding issues affecting the claims department, including software, refunds, timeframes, processes, etc.
• Assist with the evaluation and implementation of claims software, including the management of software-related issues.
• Research and manage services procured through third-party vendors, such as claims auditing.
• Prepare both recurring and ad hoc reports for management and other stakeholders requiring information regarding claims expenses, utilization, or any other claims issues.
• Attend regular meetings and conferences with regulatory agencies and PACE associations to ensure the client is compliant and following best practices.
• Act as claims representative on committees and project teams to plan and collaborate on company process improvements and expansion efforts.
• Work closely with operations and finance to partner on referral processes, IBNR accruals, encounter data submissions, and RAPS reporting.
• Work with the IT team and various vendors to coordinate, manage, and implement changes to improve efficiency, data accuracy/governance, and scalability
• Review, address, and resolve formal grievances directly about claims.
• Work as liaison with center directors and center staff to ensure excellent customer service, provider, and utilization management.
• Perform other special projects as assigned by company management.

Functional Category: Supervision

Estimated Percent of time Spent – 20%

• Effectively supervises and manages direct reports and provides, by example and leadership, motivation and direction to employees of the organization.
• Carries out supervisory responsibilities by the organization's policies and applicable state and federal employment laws.
• Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; recognizing and rewarding employees; corrective disciplinary procedures and practices (under direction of supervisor and in partnership with Human Resources), addressing complaints, and resolving problems.
• Ensure annual employee performance reviews are conducted in a timely and effective manner. Evaluates the performance of employees for compliance with established policies and objectives of the organization and contributions to attaining objectives.
• Help set the tone of the department to ensure morale, teamwork, and the positive employment culture of the organization is maintained.
• Regularly schedules leadership/management, department, and staff 1:1 meetings to provide leadership, development, and a forum for communication to ensure coordination and collaboration in meeting organizational and individual goals.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

REQUIRED

Education

• Bachelor’s degree in accounting or a related field from an accredited college/university

Work Experience and Qualifications

• Minimum of ten years of experience in healthcare claims processing, or equivalent combination of education and experience.
• Experience with researching and resolving errors that result in refunds and adjustments required.
• Current experience and strong knowledge of co-pays, deductibles, co-insurance, coordination of benefits, pre-existing conditions, primary and secondary insurance, and stop loss.
• Current experience and knowledge of general accounting, medical terminology, ICD-9, CPT coding, CMS 1500, UB2004, and other claim forms and systems.
• Strong familiarity and skill with Microsoft Office Suite, Check-writer System, and Managed Claim Optimizer (MCO).
• Strong management skills and a minimum of two years of experience supervising staff.

Other Knowledge, Skills, and Abilities Required

Computer Skills

• Must be computer proficient and possess experience with Microsoft Word, Excel, and Outlook.
• Must be able to quickly learn specific software and new applications.
• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
• Able to analyse data and statistics and draw reasonable conclusions, and compile accurate reports.
• Experience with P/L and developing and managing budgets

Language Skills

• Ability to read, analyze, and interpret regulations and other documents.
• Strong interpersonal skills and ability to effectively and tactfully present information to, and communicate with, co-workers, employees, and others.
• Possess exceptional English written and verbal communication skills, including accurate grammar and business correspondence knowledge.
• Ability to read and write memos, reports, and correspondence that conform to prescribed style and format.

Reasoning Ability

• Ability to define problems, collect data, establish facts, and draw valid conclusions.

Other Skills and Abilities

• Able to establish and maintain cooperative and positive working relationships.
• Organized, detail-oriented, diplomatic, proactive, self-motivated, dependable, and driven by excellence.
• Even-tempered and able to balance multiple tasks by changing deadlines and priorities in a fast-paced environment.
• Ability to work sensitively and effectively with individuals of diverse ethnic and cultural backgrounds.
• Client is dedicated to empowering seniors to live independently, allowing them to age in their own homes and communities safely. Client offers an alternative to nursing homes through its Program of All-inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals who are committed to creating personalized care plans for each participant. At Client, our team members are our greatest asset and have a significant impact on the lives of our participants every day. When you join Client, you'll work alongside talented, respectful, and passionate colleagues within a patient-centred care model.
• Client is committed to equal opportunity and affirmative action, and we strive to create a diverse and inclusive workplace. We consider all qualified candidates for employment without discrimination based on race, color, religion, sex, sexual orientation, gender identity/expression, national origin, disability, protected veteran status, pregnancy, or any other protected status. Salaries are determined by various factors such as qualifications, experience, and location, and do not include potential bonuses or benefits. Our extensive benefits package includes medical/dental/vision insurance, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k) savings, paid time off, and company-paid holidays.

Seniority level

• Seniority level

  Director

Employment type

• Employment type

  Full-time

Job function

• Job function

  Management, Health Care Provider, and Strategy/Planning

• Industries

  Hospitals and Health Care, Health and Human Services, and Nursing Homes and Residential Care Facilities

Referrals increase your chances of interviewing at TriOptus by 2x

Inferred from the description for this job

401(k)

Vision insurance

Medical insurance

Disability insurance

Paid maternity leave

Paid paternity leave

Pension plan

Child care support

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