Director Claims Operations

Director Claims Operations

Requirements

• Bachelor’s degree in mathematics, accounting, statistics, computer science, or related field with 8 years of related experience, 5 years management experience and experience operating strategically. Equivalent combination of education and experience may be substituted.
• Knowledge of practices, principles, procedures, regulations and techniques as they relate to claims and related functional areas. Facets experience required.
• Must have fiscal management, budget preparation, expenditure control and accurate record keeping and management experience.
• Must have knowledge and experience with data analysis techniques and with programming languages used in retrieving data (such as SAS, Easytrieve Plus, Access, and SQL languages).
• Current operations knowledge of the health insurance field.
• Collaborative, team-based perspective.
• Ability to travel to all Plans and work on quality issues with geographically diverse customers and staff.
• Project management and effective communication skills; quality management and quality improvement principles and techniques.
• Leadership techniques and approaches to ensure effectiveness in leading a multi-layer organization.
• Technical auditing practices and statistical sampling methods.

Responsibilities

• Direct leadership for Cambia Claims performance metric management, telecommunications and technology management, customer data management, audit and reporting.
• Responsible for the analytical process of claims data; accountable for developing data integrity and data reconciliation with other departments.
• Leads projects and coordinates data requests as needed. Performs complex/critical projects and provides cost saving recommendations to senior leadership. Projects include research, planning and developing solutions and future obstacles.
• Provides complex analysis and recommendations regarding adequate claims services to ensure participation and cost containment goals are sustained.
• Develops and directs claims-related activities to ensure that Cambia effectively leads and implements initiatives required to successfully serve customers consistent with strategic direction.
• Maintains a leadership team approach to resolve problems or issues of overall importance. Matters that cross functional lines directly involve the position’s input as well as that of other company officers, requires frequent, direct contact and close communications with peers and executives across Cambia.
• Direct the preparation of plan, group and other performance reports to measure claims timeliness and quality, and ensure their validity.
• Direct each Regence Plan’s compliance with all large group performance guarantees.
• Direct and coordinate responses on behalf of Regence to the Blue Cross Blue Shield Association and the FEP Director’s Office on quality related issues.
• Collaborate with other Blue Cross Blue Shield Plans on quality best practices.
• Assist external auditors in the completion of their audit goals including SAS 70, annual and interim reviews, and compliance audits.
• Trend claims quality data and develops aggregate and individual plan reports as indicated.
• Prepare and/or present presentations on Cambia quality/audit results for Member Services management, Cambia Executive staff, and Plan leadership.
• Forecasts claims volumes, in coordination with Cambia Business Intelligence, so that adequate staffing can be acquired and trained to meet the expectations of customers, providers and internal partners.
• A major emphasis of the position is to continually strive toward increased customer satisfaction while maintaining or increasing operational efficiency. This is accomplished through motivating all plans toward standardization resulting in increased productivity, increased accuracy and focus on member satisfaction and relative activities.
• Acts as a member of the Management Staff and attends all appropriate meetings to keep members informed of claims related activities as they relate to company objectives and goals.

Preferred Qualifications

No preferred qualifications provided.