Claims Director

To supervise, monitor and evaluate the needs and objectives of claims department in order to ascertain that company directives and goals are being met.

Essential Functions & Responsibilities

  • Supervise, monitor and coach the claims management team and their staff in their daily responsibilities.
  • Answers and resolves claims operational problems and issues that arise during the companies daily activities.
  • Maintain working knowledge of all systems used in the adjudication of claims.
  • Monitor the Productivity and Quality of assigned Departments to ensure that company standards are being met.
  • Maintain turn around times of assigned departments at the expected company and industry standards.
  • Report to VP of Claims Operations any problem areas requiring further attention.
  • Participate and conduct with the VP of Claims Operations weekly staff meetings with the claims management staff to provide ongoing feedback of overall departmental performance.
  • Maintain reporting of department receipts, productivity, quality and analysis of overall departments’ performance.
  • Prepare analysis reports that identify any potential operational issues that require follow up to ensure compliance within the company.
  • Review system limitations and department limitations and propose alternative methods of resolution to the VP of Claims Operations.
  • Review system enhancements for the claims adjudication systems.
  • Prepare and maintain department processing guidelines, policies and procedures.
  • Completes annual reviews of direct reports and reviews the claims op staff reviews with respective managers.
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Special projects and other duties as assigned by senior management.
  • Perform additional duties and related essential duties as assigned.

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Education and/or Experience

  • Bachelor’s degree or 10 years equivalent work experience.
  • Minimum 10 years experience in a medical office claims environment with increasing levels of responsibility.
  • Demonstrated knowledge of ICD-9, ICD-10, CPT-4 and HCPCS coding.
  • Demonstrated knowledge of Medicare, Medicaid and Commercial lines of business claims adjudication rules.

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