Director - Claims

The Director of Claims and Encounters provides strategic leadership, fiscal accountability and operational excellence for the Presbyterian Health Plan (PHP) Claims Operations and Encounter Resolution teams. This leader is responsible for directing the operations of the Claims Department for Commercial/ASO, Medicare and Medicaid products, to ensure that all functions related to claims receipt, processing and payment are performed within the established quality and quantity standards. You will lead the encounters resolution team and be the leader responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role is accountable to drive execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market-leading practices.

 

In addition to operational, this leadership role is accountable to champion and execute on the prioritized deployment of Auto-Adjudication methodologies, use of Robotic Process Automation (RPA/Bots), increased first pass and overall encounter acceptance and process simplification to achieve operational optimization and cost effectiveness. This role will lead department strategic objectives and have responsibility to achieve measurable gains in reduced cycle times and improve functional effectiveness in departmental processes. This role will make use of deep claims and encounters expertise to improve the member and provider experience.

 

This position is intended to be conducted in the state of New Mexico. 

• Bachelors degree in Finance, business, healthcare or related field.
• MBA preferred.
• At least 10 years of healthcare specific operational leadership experience with a focus on Health Plan Claims Operations
• At least 5 years of experience leading in a similarly complex function.
• Ability to assimilate business group strategy/objectives to develop appropriate programs and solutions that support business goals. 
• Demonstrated experience navigating, influencing and leading within a highly matrixed environment.
• Advanced experience working on complex analytical projects with diverse teams and developing data driven and outcome-based initiatives to improve business decision making and operational efficiencies.
• Strong understanding of customer experience and lifecycle, as it relates to experiencing health plan benefits.
• Deep understanding of operations in the Health Care industry and a strong acumen of business processes, including operations, delivery models and revenue models.
• Content knowledge related to program outcomes evaluation, BI tools (e.g., BO), data visualizations tools (e.g., Tableau).
• Ability to summarize and clearly communicate ideas and processes, both orally and in writing.
  
  Skills:
• Anticipating & Addressing Customer Needs
• Educating Employees, Customers & Transferring Knowledge
• Functioning as an Effective Contingent Member
• Diagnosing & Resolving Complex Problems
• Acquiring & Applying Superior Skills to achieve Quality Outcomes
• Functioning as an Effective Team Member
• Ability to present to various audiences

• Accountable for leadership of department managers and supervisors with responsibility for workforce planning, implementing process improvement initiatives and staff development.
• Leads and partners with business and technical subject-matter-experts on operational and transformational initiatives, in an agile manner, to enhance automation, innovation, process improvements, and maximize efficiencies across the continuum.
• Effectively translates strategic goals into specific operating and resource plans.
• Establish and maintain key claims and encounters KPIs to demonstrate operational performance.
• Drives continuous improvement activities in standard process, adjustor behaviors and claims outcomes.
• Maintains market leading claims and encounters quality assurance and testing center of excellence.
• Monitors departments budget and are responsible for monthly variance reporting.
• Ensures regulatory compliance across all areas of accountability, while delivering innovative and creative solutions that improve member experience.
• Drives contract NM Medicaid compliance to all appropriate encounters metrics and TATs.
• Manages key vendors to validate contract compliance on claims transactions and encounters receipt and acceptance measures.
• Ensures that all claims and encounters are processed according to pre-determined production and accuracy standards, within regulatory guidelines.
• Accountable for the preparation and electronic distribution of desk top policies and procedures for both the Claims and Encounters department with support to Health Services, Member Services, Provider Services and Enrollment Demonstrates advanced analytical and problem-solving skills as well as a system thinking approach to resolving complex benefit and provider process issues resulting from contract obligations.
• Responsible, on behalf of PHP Operations, to support activities to resolving complex benefit problems, addressing cross-functional questions (i.e. from Configuration, Information Services, Claims, Encounters, Enrollment, Member Services, Provider Services, et al.).
• Regularly evaluate changes/updates of relevant information to the appropriate individual(s) to facilitate further process improvement.
• Provides research, analytical, information support, and recommendations when requested, for decision making.
• Assist in benefit and provider contract review to verify intent and assure consistency between the benefit/provider contracts and Operations activities.
• Assist in determining business needs by effectively conducting fact-finding interviews and leveraging various tools and analytical methods and then summarize findings in a coherent manner to develop and propose appropriate solution.
• Support day-to-day consultation to business users and participate and contribute cross-functional project teams.
• Support development and adoption of cross departmental analytics / dashboarding to provide visibility and decision support on impacted projects.

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Learn more about our employee benefits:

https://www.phs.org/careers/why-work-with-us/benefits

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

 

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

 

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

 

About New Mexico

New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $77.90/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.