Senior Director II, Enterprise Shared Services

Job Summary

The Senior Director II, Enterprise Shared Services ("Senior Director II") is an out-of-the-box, critically thinking senior leader who is accountable for leading and continuously refining and improving the accuracy of claims payment processes and encounter submissions, and L.A. Care’s anti-fraud program. The Senior Director II provides leadership in the ongoing development and implementation of processes and protocols that are responsive to internal and external customer needs, and supports fulfillment of LACs mission and values for all products. The Senior Director II will lead a team of senior leaders responsible for departments reporting up to this position.  The Senior Director II will lead to ensure enterprise-wide business functions and processes can be effectively and efficiently administered and adapted via the existing and future Information Systems infrastructure to meet L.A. Care’s strategic and annual goals, solidify competitive position, and address underlying strategic and tactical objectives affecting operating costs, revenue, member and provider satisfaction, and compliance with internal and governmental policies.

This position will work closely with executive/senior leadership and/or their assigned designees to ensure alignment of performance strategies with current and future enterprise strategic decisions. The Senior Director II will collaborate extensively with business areas and internal and external I.T. personnel to represent and define business needs, and will lead and direct technical activities impacting key operational performance metrics in compliance with contractual, regulatory, and accrediting requirements, and county programs such as: quality, encounters, provider disputes, cycle time and efficiency rates of customer self-service rates, claims and enrollment processing, electronic submission rates, claim and enrollment first pass rates, claim cost program controls.  This position reports to the Chief Operating Officer (COO) and will direct all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Responsible for delivering on the strategic direction for L.A. Care's Payment Integrity operation. Establish business cadence (weekly, monthly, quarterly business reviews) to ensure results are met and exceeded or evolve existing business cadence to drive higher levels of performance. Ensure the right balanced scorecard is in place for the businesses and ensure we have the best possible metrics in place to manage the operation on an ongoing basis.

Constantly collects and analyzes performance data (e.g. financial, operational) in order to identify new opportunities for the business. Clearly understand the competitive landscape – competitor strategies, positioning, strengths and weaknesses, and uses these insights to drive the development of strategy and action plans. Ensure overpayment recovery and reporting are operating with high quality in order to manage provider escalations and disputes. Identify and execute on new opportunities for increases in efficiencies and performance. Apply analytical / quantitative approach to problem solving - knows how to obtain and use data, and comfortable with statistical concepts. Accountable for financial and non-financial 

Partners with internal service units organizations (e.g. analytics, information technology, finance, human resources, communications, and marketing) to ensure planned results are delivered. Develop an excellent working relationship with clients, both at the executive and daily operational levels. Develop an internal and external communication strategy to proactively share with clients the value being driven for them and simultaneously engage the employee base within the business.

Responsible for setting critical goals and upholding a high standard of operational performance throughout the teams in assigned organization. Establish mechanism to drive for continuous improvement within the business; past experience driving process improvement initiatives; small scale and large scale is highly desired. Ensure oversight policies and procedures, with effective processes are operational in order to achieve high quality delegated oversight.

Leads, directs and manages the day-to-day scope of business workload and requests via extensive interface and collaboration between business and I.T. personnel including user prioritization of systems development.  Directs key production system processes and analysis and resolution of requests and problems impacting front-line business users and external parties (providers, accounts, brokers, other Plans, government agencies, etc.). Represents and manages L.A. Cares' interests externally and provides expert systems/operational knowledge to resolve complex business issues impacting Claims, Service, and Member Administration processing. Leads business management processes (e.g., Mandates, etc.).

Guides and executes substantial portions of analysis, planning and implementation of both divisional and corporate initiative project responsibilities with clear operational ‘running the business’ impacts to ensure timely and complete fulfillment of project objectives. As such, defines and addresses cost/benefit information, deliverables and milestones, staffing and budget impacts, risks and dependency issues, task management, status reporting. Researches and maintains knowledge of industry business practices and technology to define, champion, participate or advise enterprise program management in the formulation and deployment decisions of strategies, goals and recommendations to advance operational capabilities, service and cost management.

Duties Continued

Directs, manages and maintains highly technical electronic data interchange system adjudication files that have significant impact upon claims and account adjudication results or controls such as: benefit files, external message and product files (EOBs, remits, ID cards, contracts, etc.) reimbursement tables, transaction directing, vendor interfaces, security, etc.

Leads, motivates, directs, plans, organizes and evaluates managerial and staffing and performance levels, assignments, and work processes and supporting tools impacting area workload tied to responsibilities and goals herein. Establishes and manages department budgets. Sets area goals, metrics and tactics based on evaluation and negotiation of business requirements, deadlines and strategies. Performs status reporting on workload and performance. Develops skills and abilities of area staff. Delegates authority and responsibility as appropriate.

Directs business analysis, design (requirements and system specification), testing, implementation, production maintenance and development of supporting procedures for operational processing systems to provide a high-performing enterprise-wide operating environment. Encompasses support for changes and problem resolution involving inter-Plan relations and policies, state and federal mandates, day-to-day business needs (products, policies, procedures), and many strategic corporate initiatives. 

Evaluates, improves, plans, implements, and expands operations processing applications (Claims, Service, Enrollment, Plan to Partners) to align with operational and corporate strategy, comply with government requirements, and ensure efficient integration with business and systems functions and adjudication. 

Plans, implements, and directs project and day-to-day operations support as described above regarding operational vendor relationships and arrangements of functional outsourcing contracts – Business Processes, Systems Maintenance/Development (e.g., Emdeon, etc.), Delegated Plans, Electronic.

Transaction Partners, etc. Ensures effective systems processing capabilities to comply with policies, products, and contracts as well as negotiating and managing budgets of multi-million transaction processing fees.

Responsible for the supervision of assigned staff including but not limited to mentoring, training, performance management, hiring, corrective action and staff development.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:
At least 10-12 years of relevant business experience in operations management in a healthcare industry environment with at least 10+ years of management/supervisory experience.

Experience leading various Payment Integrity functions such as: claims editing; enrollment integrity/Coordination of Benefits (COB); Fraud, Waste, and Abuse (FWA) strategies; overpayments identification; claims auditing; and healthcare subrogation/Third Party Liability (TPL).

Skills

Required:
Strong financial analysis, risk management, and analytical skills for network analysis.

Proven ability to produce superior results in a financial performance-oriented environment.

Excellent administrative and organizational skills.

Demonstrated ability to communicate effectively and professionally with internal and external contacts at all levels.

Proficiency with Microsoft Office applications (Word, Excel, Access, PowerPoint).

Familiarity with safety net healthcare programs and related issues.

Must possess strategic thinking, analytical, organizational, and planning skills.

Executive presence with strong business and people leadership capabilities.

Ability to work and create structure in complex and ambiguous situations and respond flexibly in time sensitive situations.

High level of organization, planning, prioritization and attention to detail.

Ability to work and create structure in complex and ambiguous situations and respond flexibly in time sensitive situations.

Track record of delivering measurable improvements in operations.

Conflict/negotiation management demonstrated influencing skills.

Excellent communication skills to include written, verbal and presentation.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information