The Director of Claims Operations is responsible for directing and coordinating all aspects of health plan claims processes, claims customer service and capitation and member excess billing and collections.

• Creates functional strategies and specific objectives for the claims department through planning, design, development, documentation, implementation and evaluation of policies and procedures to ensure accurate and timely claims processing and billing and exceptional customer service.
• Acts as liaison with and has oversight of Third Party Adjudication (TPA) company to ensure efficient, accurate and timely processing and payment of claims.
• Actively monitors claims adjudication process, claims inventory and aging to ensure compliance with plan policies and procedures and state and federal regulations as applicable.
• Oversees supervision and training of department’s staff and functions.
• Collaborates and communications with other departments on claims issues, related projects and inter-departmental operations issues and develops effective, actionable solutions to ensure optimal understanding, communication and follow-up with providers and internal customers.
• Handles escalation of provider claims issues. Conducts investigation into root cause of issue and follows appropriate escalation path to ensure resolution.
• Oversee research, resolution and tracking of claims adjudication problems, administrative appeals and capitation billing to ensure accurate and timely payment and communication to providers.
• Tracks, monitors and reports on functional area key performance indicators on a current basis.
• Provide courteous, respectful, and knowledgeable customer service.
• Perform all other duties as assigned.

Requirements:

• Bachelor’s degree required.
• 2-3+ years of supervisor-level experience managing employees that process claims processes and/or claims processes, functions or workflows.
• Knowledge of NY Medicaid and Medicare rules and regulations required.
• Skilled in prioritizing, problem-solving, multi-tasking, and meeting deadlines.
• Exceptional communication and customer service skills.
• PC skills, including Microsoft Office.
• Demonstrates discretion in handling confidential and sensitive information.

Physical Requirements:

• Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication.
• Ability to sit 90% of the day.
• Ability to express self verbally and in writing.
• Frequent sitting, standing and walking.
• Visual ability sufficient to read data on computer screen and paper documents.
• Extended periods of computer use
• Bloodborne Pathogens Exposure Category III- Employee who rarely has contact with

Compensation & Benefits:

Competitive Salary with:

• 401K with generous Employer match
• Medical, Dental, Vision plans
• Tuition Reimbursement for BSN after 6 months of employment
• Exceptional work/life balance - no rotating shifts
• Partially funded HSA
• Employee Recognition Platform
• Paid Time Off, Holidays, and Extended Sick Leave
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Much More!!

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About Nascentia Health:

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.

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Nascentia Health is an Equal Opportunity Employer (EOE)

Employment is contingent upon negative results of a pre-hire drug screen