Director of Claims

New Haven, Connecticut
Metroplus Health Plan
About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Director of Claims has overall responsibility and accountability for effectively and efficiently leveraging staffing and technology in delivering the claims processing and claims service for MetroPlus Health Plan. The position will direct strategic analysis and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial, Exchange and Medicaid service lines. The incumbent sets strategy for the claims business units and is responsible for integrating the various components of the business to ensure operational and developmental goals are achieved.

Job Description

• Develop and execute strategic initiatives and programs to enhance existing functions and develop new processes in support of corporate initiatives and requirements.
• Direct and oversee the Claims Processing Unit and, the Claims Service Unit. Establish administrative priorities and accomplishments for each area, manage area directors and managers.
• Monitor claims inventory, cycle time processing and work quality to assure conformity with corporate objectives and goals.
• Establish plans of action, allocation of resources, schedule overtime, etc., to ensure operational efficiency consistent with corporate and departmental goals.
• Ensure adherence to all Legislative, Regulatory and Contractual requirements.
• Conduct special projects including business analyses, strategic planning, and implementation efforts on new business acquisitions and changing corporate requirements.
• Coordinate and supervise operational analyses and implementation support on major workflow and activity modifications.
• Recommend changes for system design, methods, and workflows affecting the assigned departments.
• Develop, implement and maintain claims policies and procedures.
• Liaison between claims and configuration to ensure claims rules are implemented and claims are processed accurately.
• Act as a consultant for senior management from other departments for, but not limited to reimbursement methodologies, processing protocols and provider negotiations.
• Manage the overall budget in support of the responsibilities of the areas and corporate initiatives and responsibilities.
• Oversite of claims process of delegated vendors including but not limited to the TPA, dental vendor, vision vendor and other vendors for which claims is outsourced.
• Oversee the testing and auditing of claims
• Manage the claims correspondence with providers and members

Minimum Qualifications

• Bachelor’s degree or equivalent combination of education and work experience.
• A minimum of 8 years senior leadership experience with at least 5 years of experience in claims management in the healthcare or insurance industry.
• A demonstrated track record of driving the organizational and operational changes in the day-to-day business of a high-volume operation using current and new technology, achieving cost benefits and service excellence.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication