Head of Care Management Operations

HYBRID REMOTE Director of Claims Operations role offering low-cost medical coverage, generous paid time off and 403B Retirement plan with company match This Jobot Job is hosted by: A leading Healthcare organization specializing in Fertility and family planning with more than 2 decades of success in managing family-building benefits. We are the largest, most experienced fertility benefit management company in the country offering inclusive family-building solutions to employers, health plans and individual patients. From integrated fertility management, including medical treatment, pharmacy, and reproductive genetics, to surrogacy and adoption, our mission is to help build families by providing access to the best network of doctors, technology and emotional support at the lowest cost. Our programs include an integrated medical and pharmaceutical model that is unique to the industry. Its dedicated nurse care managers, all with experience in reproductive endocrinology clinics, guide employees through every step of their fertility journey, and are available 24/7. Dental Coverage thru Guardian ~9 company paid holidays. ~401K Retirement plan with Company match ~Short term and long-term care coverage ~Flex spending account ~Health Savings Account We are looking to hire the Director of Claims Operations to work a HYBRID Remote work schedule with 2 days work from home and 3 days in the Greenwich CT office. A bachelor’s degree is required for this role, and MUST come with 5 to 7 years supervisory experience managing and training a Claims and Customer Service unit with a healthcare payer, delegated vendor, or Third party Administrator supervising a team. Additionally, you must have knowledge of DRG/ICD-9/10, NDC/GPI, CPT/HCPCS, and RVU coding, as well as knowledge of current commercial health insurance product options, including HMO, PPO, EPO, high deductible plans, copay/coinsurance variations, and HRA’s/HSA’s. Knowledge of NCQA Guidelines, URAC Accreditation and Utilization Management desirable as well as experience with pharmacy benefit management, disease management, care management or the pharmaceutical industry desirable. Expertise in claims adjudication, including interface with payers with or without delegation, eligibility and benefit determination, and member copay/coinsurance allowances. ~Working knowledge of electronic commerce, including EDI submission and payment of provider claims, EDI submission to payers, EFT, transmission of forms, and web portal interface for providers and members. ~Prepares and presents a variety of management reports, including explanations of variances, significant trends, and recommendations for change or resolution. Keeps department management adequately informed of issues, trends, challenges, and problem identification/resolution. ~Plans, organizes, and manages both Customer Service and Claims functions. Works “on the floor” and coaches team members in the supervision of all tactical and strategic activities. ~Drives performance by ensuring all employees are trained, and work is completed in an accurate timely manner and meets company and contractual standards. ~Monitors and tracks staff and call center department performance against established productivity and quality metrics, including regular audits assessing department performance. Identifies and acts on both positive and negative performance trends to ensure attainment of goals. ~Leads quality efforts including phone call monitoring for quality, agent demeanor, technical accuracy, and conformity to HIPAA, URAC and Company standards. Addresses agent performance as needed. ~Monitors work queues, prioritizes incoming authorizations, and effectively delegates tasks to team staff to ensure company standards and contract obligations are met. ~Assists staff in troubleshooting techniques as well as difficult customer issues. ~Oversees day-to-day claims operations, including claims evaluation, adjudication and customer service in accordance with contract and Company quality and production standards. ~Reviews claim audits for completeness, accuracy of information and compliance with policies, standards and procedures. Resolves any issues or directs claim to team lead/area manager for resolution prior to payment. ~Recommends changes to workflow, procedures or policies and ensures that all Customer Service and Claims employees are fully informed, understand and implement changes. ~Identifies, leads, develops and organizes training, re-training and cross-training of team members and new employees as appropriate and in coordination with Human Resources.