[Hiring] Director of Claims Processing and Payment Integrity @CenterWell

Role Description

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 requires an in-depth understanding of TPA business, claims processing, and how organization capabilities interrelate across the function or segment.

The Director contributes to overall provider satisfaction by:

• Paying claims accurately and timely
• 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
• Supporting technical/operational procedures and processes
• Implementing strategic plans, new business contracts, driving goals and objectives, and improving performance

Provides input into functions strategy.

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

Requirements

• Master's Degree (Preferred)
• Experience leading projects and processes (Preferred)
• Experience in Financial Recovery (Preferred)
• Experience with Plexis and Oracle systems (Preferred)
• Knowledge of LucidChart or Visio (Preferred)
• Project Management Professional (PMP) Certification (Preferred)
• Bilingual in Spanish and English (Preferred)
• Progressive experience in contracting or claims area for a health solutions industry (Preferred)

Benefits

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance
• Many other opportunities

Additional Information

• Remote considered, but preference is onsite in Miramar, FL.
• Scheduled Weekly Hours: 40
• Pay Range: $138,900 - $191,000 per year
• This job is eligible for a bonus incentive plan based upon company and/or individual performance.