ASSOCIATION FOR COMMUNITY AFFILIATED PLANS
Director, Claims
ASSOCIATION FOR COMMUNITY AFFILIATED PLANS, Washington, District of Columbia, us, 20022
With a mission to heal and inspire the human spirit, Inland Empire Health Plan (IEHP) is one of the top 10 largest Medicaid health plans and the largest not-for-profit Medicare-Medicaid plan in the country. In its 29th year, IEHP supports nearly 1.6 million members who are enrolled in Medicaid and has a growing network of over 8,000 providers and nearly 4,000 Team Members (Employees). Through dynamic partnerships, award-winning service, and a tradition of quality care, IEHP is fully committed to its Mission, Vision, and Values.
IEHP has consistently achieved outstanding employee engagement scores from their 4,000+ Team Members and was most recently recognized and awarded the designation of ‘Great Place to Work’ for a third year in a row!
About the Position: Reporting to the Senior Director, Claims, the Director, Claims is responsible for the direction and oversight of all medical claims processing, provider disputes & appeals, quality assurance, and training activities. Additional responsibilities include ensuring regulatory compliance, strategic planning, and staff development.
Responsibilities:
Ensure all claims, appeals and disputes are accurately handled within Federal and State regulatory requirements
Oversight of quality assurance audits and initiatives focused on payment accuracy and streamlined processes
Oversight of all department training activities
Primary department representation for internal/external claim audits and regulatory appeals and inquiries
Responsible for ensuring regulatory reporting and fulfilling corrective action plans for identified deficiencies
Coordinates department purchasing needs and originates RFP’s and RFQ’s for needed services
Prepares department budget and staffing plan
Ensures all department policies and provider manual claim policies are maintained
Interacts with other IEHP departments to collaborate on key initiatives, issue resolution and Lean activities
Experience Requirements:
Five (5) years healthcare administration experience required
Four (4) or more years in a leadership capacity required
Two (2) years of experience with an HMO or managed care experience required
Medi-Cal/Medicaid claims experience required and Medicare/DSNP/ACA Exchange experience preferred
Educational Requirements:
Bachelor’s degree in business administration, accounting, or healthcare from an accredited institution required
Master’s degree from an accredited institution preferred
Knowledge & Skills:
Solid understandings of rules and regulations governing Medi-Cal benefits and claims adjudication practices and procedures
Principles and techniques of supervision and training
Microcomputer literacy preferred
Commitment to Team Culture: The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.
Salary range: $154,128.00 – $254,300.80 based upon related/relevant experience and internal equity.
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IEHP has consistently achieved outstanding employee engagement scores from their 4,000+ Team Members and was most recently recognized and awarded the designation of ‘Great Place to Work’ for a third year in a row!
About the Position: Reporting to the Senior Director, Claims, the Director, Claims is responsible for the direction and oversight of all medical claims processing, provider disputes & appeals, quality assurance, and training activities. Additional responsibilities include ensuring regulatory compliance, strategic planning, and staff development.
Responsibilities:
Ensure all claims, appeals and disputes are accurately handled within Federal and State regulatory requirements
Oversight of quality assurance audits and initiatives focused on payment accuracy and streamlined processes
Oversight of all department training activities
Primary department representation for internal/external claim audits and regulatory appeals and inquiries
Responsible for ensuring regulatory reporting and fulfilling corrective action plans for identified deficiencies
Coordinates department purchasing needs and originates RFP’s and RFQ’s for needed services
Prepares department budget and staffing plan
Ensures all department policies and provider manual claim policies are maintained
Interacts with other IEHP departments to collaborate on key initiatives, issue resolution and Lean activities
Experience Requirements:
Five (5) years healthcare administration experience required
Four (4) or more years in a leadership capacity required
Two (2) years of experience with an HMO or managed care experience required
Medi-Cal/Medicaid claims experience required and Medicare/DSNP/ACA Exchange experience preferred
Educational Requirements:
Bachelor’s degree in business administration, accounting, or healthcare from an accredited institution required
Master’s degree from an accredited institution preferred
Knowledge & Skills:
Solid understandings of rules and regulations governing Medi-Cal benefits and claims adjudication practices and procedures
Principles and techniques of supervision and training
Microcomputer literacy preferred
Commitment to Team Culture: The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.
Salary range: $154,128.00 – $254,300.80 based upon related/relevant experience and internal equity.
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