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Director, Claims Payment

St. Louis , MO, USA | Centene Corporation

  • Industry:
    Healthcare - Hospitals
  • Position Type:
    Full-Time
  • Functions:
    Operations / Production
  • Experience:
    7-10 years
Job Description:
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The Director, Business Operations Claims Payables leads and manages teams responsible for the implementation and management of highly specialized and regulated processes involving Claim Payables, including cross-accumulation of member cross share across multiple claims systems, and disbursement of Explanations of Benefits (EOB’s) and Explanations of Payment (EOP’s) to members and providers, and delivery of Electronic Remittance Advices (ERA’s) to providers. The Director, Business Operations Claims Payables is considered the Process Owner of these functions.


Partners with IT development, Product Management, Health Plan Compliance and Operations, Vendor Management, Product Development, Finance and Treasury, Contact Centers, and Provider Network resources to collaboratively and rapidly deliver solutions to increase claim payables processing efficiency and compliance, reduce errors and member/provider complaints, and provide return on investment to business operations. Provide strategic oversight, governance, and controls for Claims Payables.


Position Purpose:


Develop and implement programs centered on quality and operations excellence


Develop and monitor service levels to ensure compliance with state, federal, and company metrics and standards


Initiate ongoing and special projects including process improvement evaluations and analysis, department business development, ROI analysis, and annual satisfaction initiatives


Direct all membership related initiatives including identification of business need, strategy recommendation, project outline, management of deliverables, and ROI


Work collaboratively to facilitate the design, development and implementation of policies, procedures and practices related to service operations


Establish and maintain working relationships with external sources such as CMS for regulatory and compliance guidance


Develop and maintain collaborative relationships with health plans, other business units, IT partners, and oversee training and business processes as necessary


Additional responsibilities may include:


Lead and develop a team focused on accuracy and compliance of Electronic Remittance Advices (ERAs). Involves vendor management duties working with 3rd parties who distribute multimillions of dollars of funds with associated remittance advices. This team is also responsible for corporate oversight and developing best practices and process documentation for the Amisys Post-Pay System (PPS).


Lead and develop a team focused on imaged and printed payables documents [Explanations of Payment (EOPs) and Explanations of Benefits (EOBs)]. Partner and manage 3rd party vendors and who distribute these documents. Must be well versed in federal and state regulations pertaining to content, format, and availability requirements for these documents.


Manage a team focused on accurate and timely cross accumulation of member cost share toward deductible and out-of-pocket limits. Involves deep understanding of cost-sharing benefit plan design and vendor management to accurately merge claims cost share from multiple vendors to a single cross-accumulation reference database used by multiple payers.


Maintains knowledge of industry regulations, best practices, trends, applications, and technological advancements. Must be well versed in general Federal and State Claims Regulations, as well as HIPAA Transaction & Code Set Regulations for ANSI X12 EDI 835 transactions, and CAQH CORE Operating Rules for EDI 835.


Responsible for the development, implementation and management of business operations such as billing and enrollment, call center, customer service, etc. and related initiatives that impact membership for product lines and health plans. Manage service levels; identify service opportunities, new business implementations and product expansions


Experience/Experience:


Bachelor’s degree in Business or related field or equivalent experience. Masters or Advanced degree strongly preferred. 7+ years of business operations (call center, enrollment, billing, payment processing, or similar operations) experience preferably in a managed care and/or Medicare environment.


Experience working in claims payables processes at a large payer organization or in patient accounts / payment reconciliation at a large provider organization strongly preferred. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff. Health insurance and project management experience preferred.


License/Certification:


EDI Certifications, Agile Certification and Lean and/or Six Sigma Black Belt strongly desired


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