Director, Claims - Denver Health Medical Plan - Full-time / Part-time

We are recruiting for a Director, Claims - Denver Health Medical Plan to join our team!

We are here for life’s journey.
Where is your life journey taking you?

Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all:

Humanity in action, Triumph in hardship, Transformation in health.

Department

Managed Care Administration

****Remote Opportunity. Must Be a Colorado Resident****

Job Summary

As the Director of Claims and Enrollment, you will lead the strategic vision and execution of operations critical to our organization's claims and enrollment functions. Your core responsibilities involve overseeing comprehensive audits, ensuring contractual compliance, and implementing continuous monitoring practices. By leveraging your expertise, you will drive effective stakeholder communication, streamline issue resolution, and introduce innovative solutions to enhance operational efficiency.
This position provides a unique opportunity to shape and enhance the organization's claims and enrollment functions, driving continuous improvement and contributing to overall business success through strategic leadership and effective operational oversight.


Essential Functions:

• Claims, Enrollment and Configuration Operations Management
  • Oversee and manage the daily operations of the function. Adheres to the rules, regulations, and contractual requirements of CMS, CO Medicaid, CO Division of Insurance, contracted and non-contracted providers.
  
  • Manage vendor oversight program of outsourced activities to ensure the contractual performance meet expected outcomes including appropriate turnaround time, accuracy, quality assurance program(s), and issue resolution. To include
  ◦ Audit Planning and Execution:
  ▪ Lead the planning and execution of audits to assess vendor performance, compliance, and adherence to contractual Service Levels and Key Performance Indicators.
  ▪ Conduct thorough risk assessments to identify potential areas for improvement and develop audit programs accordingly.
  ◦ Continuous Monitoring:
  ▪ Establish and maintain a robust continuous monitoring framework to proactively identify and address emerging risks and issues related to vendor relationships.
  ▪ Implement key performance indicators (KPIs) and metrics to measure vendor performance and compliance on an ongoing basis.
  ▪ Leverage technology solutions for data analytics, automation, and reporting to enhance the efficiency and effectiveness of vendor auditing processes.
  ◦ Issue Resolution and Remediation:
  ▪ Lead the resolution of issues identified through audits or other operational escalations, working collaboratively with cross-functional teams to implement corrective and preventive actions.
  ▪ Monitor and track the progress of remediation efforts to ensure timely resolution of identified issues.
  ◦ Stakeholder Communication:
  ▪ Regularly communicate audit findings, performance metrics, and risk assessments to senior leadership and key stakeholders.
  ▪ Facilitate constructive dialogue with vendors to address concerns, provide feedback, and drive continuous improvement.
  (60%)
• Cross Departmental Collaboration
  • Implement operational changes necessary to maintain compliance with regulatory guidance affecting internal teams and external vendors; guarantee the organization's adherence to all applicable laws and regulations.
  • Oversee updates and changes to system configuration and team operating procedures to ensure the processing and payment of claims align with Utilization Management policies; collaborate with leadership to promptly address arising issues.
  • Collaborate with the Contracting team to verify that claims are processed in accordance with the contract and partner with Provider Relations to resolve any inconsistencies.
  • Develop, modify, review, and implement policies and procedures for pricing changes, contractual modifications, and adjustments.
  • Monitor and detect potential fraud and abuse, ensuring continuous regulatory compliance across all operations; share findings with Payment Integrity and Compliance teams.
  (25%)
• Staff Management & Training
  • Work with Direct Reports and teams to manage daily operations- Claims Manager, Enrollment manager and Configuration Lead
  • Manage the daily operations of the Claims Operations staff, including hiring, training, supervising, evaluating, and developing the Claims Manager, two Business Care Analysts, and two Claims Processors.
  • Develop, review, and present reports on productivity and accuracy.
  • Develop comprehensive training programs and ensure acquisition of knowledge related to all claims policies and procedures. Ensure vendor adherence to same policies and procedures. (15%)

Education:

Bachelor's Degree required

Work Experience:

• Five or more years in a leadership role within claims management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines. Experienced in managing claims processing for Medicare, Medicaid, CHP+, Large Group Commercial, or Healthcare Exchange, required.

Licenses:
Knowledge, Skills and Abilities:

• Demonstrated track record in creating approaches, policies, and procedures to ensure effectiveness of the claims payment and adjudication process at a health plan.
• Solid system development and evaluation abilities, effective leadership and management, and outstanding written and oral communication skills are required.
• Experience and proficiency with Trizetto QNXT is highly desired.
• Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services (“CMS”) and the Colorado Department of Health Care, Policy & Financing (“HCPF”) is required.
• Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA.
• Knowledge of bundled payments, risk-sharing, and provider capitation is essential.
• Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems.
• Able to perform effectively in a leadership role and evaluate processes for efficiency.
• Experienced in supervising staff and ensuring key tasks and goals are met on a timely basis.

Shift

Work Type

Regular

Salary

$145,224.00 - $224,471.00 / yr

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For more about our commitment to diversity visit: