Director of Claims

Oakland-Community-Health-Network; Troy (MI); Hybrid; USD 105,000 - 131,000; Full time

Job summary

Oakland Community Health Network seeks a Claims Management Director to lead planning, development, and operations of the claims system. You will guide executive decisions, implement plans, and ensure coding and billing compliance across programs.

The role requires extensive management experience in outpatient, Medicare/Medicaid billing, and professional reimbursements, with a focus on process improvement and regulatory adherence.

Qualifications

• Bachelor's degree in business administration or related field.
• RHIT or CPC certification required; must obtain if not held within 6 months of hire.

Responsibilities

• Provide strategic input on claims processing and payment decisions.
• Develop CM budget and auditing reports for leadership.
• Schedule and supervise audits related to claims issues and report findings.
• Manage day-to-day workflow and operations of claims management.
• Establish policies and procedures for claims processing and performance standards.
• Supervise department employees including hiring and performance management.
• Review settlements for compliance with procedures.
• Ensure CPT/ ICD coding accuracy and compliance.
• Analyze account details and respond to claims inquiries.
• Assist with pre-claim edits and coding guidance.
• Support providers with coding and billing documentation.
• Participate in committees and lead the OCHN Procedure Code Workgroup.

Skills

Leadership

Healthcare claims

Budgeting

Auditing

Policy development

Data analysis

Communication

Team management

Education

Bachelor's degree in business administration

RHIT or CPC certification

Tools

Claims management software

Job description

Salary Range: $104,633.00 To $130,791.50 Annually

Job Summary:

Direct overall planning, development, and operations of the claims management system. Provide recommendations to executive leadership team and implement plans regarding the claims management system.

Essential Functions:

• Provide strategic input on claims processing and payment decisions within the Claims Management (CM) Department.
• Participate in the development of the CM budget.
• Schedule and supervise internal and external audits related to claims issues and develop reports on audit findings and recommendations.
• Manage day-to-day workflow and operations of claims management.
• Establish policies and procedures for claims processing, including standards of performance, claims auditing, and other measurement techniques.
• Supervise department employees, including hiring and performance management.
• Review settled claims to ensure compliance with organizational practices and procedures.
• Verify and analyze data used in setting claims to ensure accuracy and compliance with procedures.
• Report on overpayments, underpayments, and irregularities.
• Consult with legal counsel on claims requiring litigation.
• Ensure compliance with CPT and ICD requirements.
• Analyze account details and respond to inquiries regarding claims payment or status.
• Assist with pre-claim system edits and provide guidance on coding issues.
• Support medical and behavioral health providers with coding and billing documentation.
• Participate in encounter reporting and ensure accurate coding for various programs.
• Review billing encounter forms annually to update codes.
• Provide ongoing orientation to new employees and clinical providers on coding, billing documentation, and compliance.
• Review provider medical record documentation and employee performance to monitor compliance with coding and billing regulations.
• Implement compliance plans for coding and billing accuracy and identify risk areas for correction.
• Assist with educational programs for providers and staff, including responses to provider inquiries.
• Participate in various committees and meetings as necessary, including the OCHN Compliance Committee.
• Chair the OCHN Procedure Code Workgroup.
• Maintain current industry knowledge and attend conferences for professional certifications.
• Ensure compliance with OCHN’s Health and Safety Policies.
• Oversee the administration, configuration, and maintenance of the claims adjudication system.
• Direct review and implementation of business process changes impacting the claims system.
• Establish partnerships with the Senior Leadership Team to ensure claims system accuracy.
• Lead compliance audits and remediate identified issues.
• Perform any other related duties as assigned.

Job Requirements and Qualifications

Education:

• A bachelor’s degree in business administration or a related field.

Training Requirements (licenses, programs, or certificates):

• Must have RHIT or CPC certification.
• Note: If the selected employee does not have this certification, that employee must receive the certification within six (6) months of the date of hire to maintain employment.

Experience Requirements:

• Minimum of five (5) years managerial/supervisory experience with at least five (5) years of professional experience in outpatient, Medicare and Medicaid, computerized and manual billing for third party payors.

Job Specific Competencies/Skills:

• Demonstrated effective interpersonal skills.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated effective written and oral communication skills.
• Demonstrated effective computer skills.
• Demonstrated effective project management skills.
• Ability to recognize and analyze complex operational/administrative or fiscal problems, and to recommend and implement solutions.
• Ability to work collaboratively and create a team environment that resolves problems and implements solutions in an environment that fosters system –wide continuous improvement.
• Ability to recruit, select, supervise, plan, direct, and evaluate the work of professional, administrative, and clerical employees.
• Ability to provide developmental opportunities for future succession planning and skill enhancement.
• Ability to communicate effectively, both orally and in writing.
• Ability to conduct effective meetings.
• Ability to initiate, plan, develop, coordinate and implement system wide programs.
• Highly effective project management skills.
• Highly effective interpersonal, active listening, negotiation, and conflict resolution skills.
• Ability to respond appropriately to and manage crisis situations.

Knowledge Requirements:

• Knowledge of Claims Management.
• Knowledge of the Billing Process including knowledge of computerized billing, electronic claims submissions, and outpatient billing procedures for third party carriers.
• Knowledge of coding CPT4 and ICD-9 and ICD-10.
• Knowledge of medical terminology and medical procedures as related to physician Medicaid, Medicare, and clinical support billing codes.

Oakland Community Health Network’s Core Competencies:

• Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust)
• Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus)
• Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning)
• Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)
• Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)

Additional Information

• Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.
• Must be available for meetings and events which may occur outside of standard office hours.
• Work performed primarily in an office environment.
• Hybrid (onsite/remote) work schedule available.
• The ideal candidate must be able to complete all the physical requirements of the job with or without a reasonable accommodation.

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees’ differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.