Director of Claims Processing and Payment Integrity

CenterWell; United States; Remote; USD 120,000 - 180,000; Full time

Job summary

CenterWell seeks a Director of Claims Processing and Payment Integrity to oversee adjudication of claims, audit payments for accuracy using data mining, and drive fraud recovery initiatives. This role ensures timely provider payments and cost reduction through accurate contract payments in our payer systems.

The ideal candidate has a Bachelor’s degree and 8+ years in Medicare/Medicaid claims management, experience leading cross-functional teams, strong communication, and proficiency with Excel;

Qualifications

• Bachelor’s Degree or combination of education and experience to ensure success in the role.
• 8 or more years of Medicare and/or Medicaid claims management experience.
• Able to determine the needed approach, resources, and goals to meet business objectives.
• Demonstrated experience with cross departmental collaboration.
• Experienced facilitating, consulting, and delivering complex concepts.
• Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, and Excel.
• Ability to handle multiple priorities.
• Capacity to maintain confidentiality.
• Excellent communication skills both written and verbal.
• Proficiency in analyzing and interpreting financial trends.
• Strong collaboration skills.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Responsibilities

• Oversee adjudication of claims and use technology and data mining to audit claims for accuracy.
• Detect anomalies in data, and identify over- and under-payment of claims.
• Contribute to accurate and timely processing of claims and investigations of fraud, waste and financial recovery.
• Implement strategic plans, new business contracts, drives goals and objectives, and improve performance.
• Provide input into functions strategy and cross-department collaboration.

Job description

Become a part of our caring community

The Director, Claims Processing and Payment Integrity oversees adjudication of claims and uses technology and data mining to audit claims for accuracy, detect anomalies in data, and identify over and under-payment of claims. Contributes to the accurate and timely processing of claims and investigations of fraud waste and financial recovery. The Director, Claims Processing and Payment Integrity requires an in-depth understanding of TPA business, claims processing, and how organization capabilities interrelate across the function or segment.

The Director, Claims Processing and Payment Integrity contributes to overall provider satisfaction by paying claims accurately and timely, and cost reduction by increasing the accuracy of provider contract payments in our payer systems. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, new business contracts, drives goals and objectives, and improves performance. Provides input into functions strategy.

Use your skills to make an impact

Required Qualifications

• Bachelor’s Degree, or combination of education and experience to ensure success in the role
• 8 or more years of Medicare and/or Medicaid claims management experience
• Able to determine the needed approach, resources, and goals to meet business objectives
• Demonstrated experience with cross departmental collaboration
• Experienced facilitating, consulting, and delivering complex concepts
• Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, and Excel
• Ability to handle multiple priorities
• Capacity to maintain confidentiality
• Excellent communication skills both written and verbal
• Proficiency in analyzing and interpreting financial trends
• Strong collaboration skills
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Master’s Degree
• Experience leading projects and processes
• Experience in Financial Recovery
• Experience with Plexis and Oracle systems
• Knowledge of LucidChart or Visio
• Project Management Professional (PMP) Certification