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Director, Claims Operations

Job Category:  Claims
Department:  Claims Integrity
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8728

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary


The Director of Claims Operations has overall responsibility and accountability for all aspects of claims operations while effectively and efficiently delivering and enhancing the claims processing experience for L.A. Care Health Plan. Additionally, this position will direct Claims Integrity efforts that include overseeing the Claims Intake process by researching overpaid/underpaid claims, recommending remediation plans for cross-functional team, and supporting the execution of the approved remediation plans. Work with cross functional teams to review and solution inaccurately paid claims based on claim payment rules, regulations, and provider contracts.   This position leverages experience and integrate various components of cross-functional business decisions to continuously improve claims’ processes and procedures. This position oversees the claims inventory by setting, evaluating, and monitoring the claims inventory baseline and examiner productivity metrics to ensure the timely and accurate processing of claims in compliance with regulatory requirements and organizational expectations. This position manages opportunities impacting claim denials such as authorization to ensure appropriate claims processing.

 

This position participates in the development of Claims Integrity strategies to provide a superior claims experience for internal and external business partners by ensuring prompt communication with all parties as well as timely and appropriate claim adjudication and remediation. Further, this position will participate in various forums, company initiatives, and other internal/external workgroups to support Claims Integrity. Directs all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties


Responsibility and accountability for all aspects of claims operations while effectively and efficiently delivering and enhancing the claims processing experience for L.A. Care Health Plan. Leverages experience and integrates various components of cross-functional business decisions to continuously improve claims’ processes and procedures.

 

Oversees the claims inventory by setting, evaluating, and monitoring the claims inventory baseline and examiner productivity metrics to ensure the timely and accurate processing of claims in compliance with regulatory requirements and organizational expectations. Manages opportunities impacting claim denials such as authorization to ensure appropriate claims processing.

 

Direct Claims Integrity efforts that include overseeing the Claims Intake process by researching overpaid/underpaid claims, recommending remediation plans for cross-functional team, and supporting the execution of the approved remediation plans.

 

Directs the creation and management of reporting that illustrates the impact of activity that drive specific and measureable inventory management. Provides guidance to ensure that Claims Integrity efforts are performed with the highest and most current rules, regulations, policies, business rules and industry standards.

 

Supports Senior Leadership by serving as SME for a deep understanding of all managed care contracts and payment rules; establishing strong relationships with internal and external stakeholders to define, align, and deliver specific Claims Integrity initiatives; and, by participating in organizational strategy, development, and gap analysis activities to identify incremental Claims Integrity opportunities.

 

Effectively leads and/or participates on teams focused on improving the quality of claims data, provider data, payment accuracy, and system configuration.

 

Directs staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

 

Performs additional duties as assigned.

Education Required

Bachelor's Degree in Related Field
In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Experience


Required
At least 7 years of healthcare (Medicare, Medicaid, Commercial) claims experience with 5-7 years of supervisory/management experience.

Skills

Required:
Strong interpersonal leadership skills.

 

Extensive knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.

 

Deep study and understanding of managed care contracts and payment rules.

 

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.

 

Knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.

 

Excellent interpersonal, verbal, and written communication skills required

 

Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.

 

Must be able to present findings to various levels of management, across all organizations.

Licenses/Certifications Required

Licenses/Certifications Preferred

Certified Professional Coder (CPC)

Required Training

Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Medical Coding, Claims, Medicare, Medicaid, Healthcare, Insurance

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