The Director, Claims Life Cycle Management and Implementation is entrusted with overseeing and directing the strategic enhancement of claim outcomes across existing and emerging lines of business within the Claims organization. This pivotal role involves orchestrating collaborative efforts with cross-functional teams to devise and implement project strategies, mitigate risks, monitor progress, lead process optimization endeavors, and create transformative change. Expert-level comprehension of the end-to-end claims process, adept project management skills, and exceptional communication and interpersonal abilities are imperative for success.
Essential Functions
Define and influence the functional requirements of Facets provider, configuration, and claims end-to-end adjudication processes, encompassing claim intake, pre-adjudication, adjudication, post-adjudication, and payment procedures
Develop and ensure execution of implementation plans, including timelines, budgets, and resource allocation, while ensuring risk management and adherence to project milestone
Be the conduit between technical and business perspectives, guaranteeing that technical solutions align seamlessly with business imperatives
Collaborate with business, architecture, and infrastructure units to uphold exceptional service levels and bolster stakeholder satisfaction
Lead the seamless implementation of new lines of business within the Claims organization, proactively identifying future system enhancements and opportunities
Perform detailed analysis of data, workflows, policies, procedures, organization of staff, skills and offer potential solutions to execute growth initiatives
Oversee the analysis of business processes and development of functional requirements and appropriately document and communicate captured information for validation and re-usability
Maintain diligent oversight of project progress, providing regular updates to stakeholders and driving consensus to ensure project integrity and efficacy
Manage risk and ensure implementation activities are completed on time and within budget
Conduct intricate data analysis, workflow evaluations, and policy assessments to propose and execute initiatives aimed at refining operational efficiency and resolving complex technology and process-based challenges
Organize work teams, drive consensus, and ensure end-to-end policy and process integrity to accomplish project work, including stakeholder participation; establishment of a project plan; meeting facilitation; consensus building; recommendation and decision documentation, and implementation oversight
Stay abreast of industry best practices and regulatory mandates, integrating them into claims processes to ensure adherence and compliance
Ensure compliance with regulatory and contract obligations in new business implementations
Foster a culture of continuous improvement, contributing to the development and enhancement of claims processes, while nurturing a high-performance team environment
Perform any other job duties as requested
Education And Experience
Bachelor's degree in business administration, healthcare administration, or a related field, or equivalent years of relevant work experience is required
Minimum of five (5) years of progressive experience in healthcare claims management or a related field is required
Minimum of three (3) years of project management experience is required
Facets experience is required
Management/leadership experience is required
Competencies, Knowledge And Skills
Advanced skills in Microsoft Office suite
Proven track record of successfully implementing new managed care products
Exceptional project management acumen, and a proven track record of successfully implementing new managed care products
Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets
Demonstrated strategic acumen and ability to drive operational excellence
Outstanding communication skills, both written and verbal
Effective listening and critical thinking skills
Demonstrated strong problem-solving and decision making skills
Ability to create and maintain effective working relationships
Licensure And Certification
Project Management Professional (PMP) certification preferred
Working Conditions
Standard office environment with potential for extended periods of sitting or standing
Occasional travel may be required based on business needs
Compensation Range
$108,600.00 - $190,000.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type
Salary
Competencies
Create an Inclusive Environment - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.
Seniority level
Director
Employment type
Full-time
Job function
Finance and Sales
Industries
Insurance
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