Director, Claims

Overview

The Executive Director must directly manage the day-to-day Claims operations with direct oversight of Claims managers and their performance in meeting the needs of the departmental and company goals. This position will also be responsible to actively implement policies and programs that ensure the effective and efficient operation of the Claims department objectives.

Responsibilities

• Direct the day-to-day activities, tasks, and processes to ensure the efficient operation of the claims processing units and all related tasks to meet the claims payment TAT, accuracy and production goals, and objectives.
• Direct and oversee the activities, tasks, and processes of all claims handling including payments, denials, or pending of all disability, Paid Family Leave, Critical Illness/Accident, medical, vision, health, dental, and flex claims.
• Utilize workflow to monitor, assign, and follow up on all claims ensuring proper assignments, timely handling, and correct workflow performance.
• Oversee the administration of all claims processing activities and tasks interdepartmentally.
• Reviews, examines, and directs the processing and handling of unusual or difficult claims providing information and instruction for accurate handling.
• Ensure the high dollar claims are given priority and are timely processed and routed for high dollar review and ensure their final adjudication is accurate and within the acceptable TAT.
• Track, report, and measure all claims statistics for reporting groups using available tools.
• Maintain up to date knowledge of all groups and benefit plans and ensure that staff are kept abreast of all new groups and benefit changes.
• Troubleshoot and analyze root causes for second handling of claims using systems, and coordinate all activities required to correct quality issues.
• Review Fast Track Examiner Portal and identify all processes affecting efficient/effective use of this application and provide support to effect best use of this application.
• Consults with specialty areas to ensure timely handling of all Anthem /Salesforce Inquiries.
• Oversee/and coordinate with Claims managers to ensure the timely handling and assignments of all claim correspondence.
• Coordinate with Claims managers on all aspects check maintenance functions: voids, overpayments, refunds, remails, stale date and adjustments to ensure they are done timely and accurately.
• Coordinate with all claims managers to ensure all JAA Anthem failures reported are done timely and accurately.
• Lead and motivate both union and non-union staff to meet performance expectations and manage their performance in accordance with departmental and company policies.
• Provide leadership, direction, and support to all the claims management team working in collaboration with other Claims Department personnel.
• Support Claims AVP in managing the oversight of the Claims department in various areas, as necessary.
• Review High dollar claims for accuracy and provide signatory sign off on checks requiring such.

Qualifications

• Bachelor's degree in business or management or associate degree or equivalent experience.
• New York State A&H adjuster license (can be obtained after employment, but conditioned on passing the exam and all required application questions.)
• Ten or more years supervisory and management experience required.
• Ten or more years work experience in handling health insurance or self-funded medical, disability, Paid Family Leave claims
• Experience in claims systems and understanding of system technology that is used in claims handling.
• In-depth knowledge of claims handling, industry terminology, and claim related medical terminology.
• Knowledge of supervisory principles and practices
• Knowledge of the functions of management including planning, organizing, leading, and controlling functions and theories.          
• High level of organizational, problem solving and analytical skills.
• Excellent written and verbal communication skills.
• Excellent interpersonal skills with leadership qualities.
• Team player and willing to collaborate with management team.
• Experience with claims systems and knowledge of the operational systems to handle claim functions.
• Good computer skills, including skills in MS Word and Excel.