The Senior Vice President of Healthcare Claims Management is a key leadership role responsible for overseeing all aspects of claims processing operations, encounter submission and health plan enrollment. This is a strategic position that drives process improvement initiatives, ensures compliance with contract requirements and industry standards, fosters a positive culture, and impacts the organization’s success in delivering high-quality healthcare services to our members.
The successful candidate hired for the position, will be required to work onsite at the Alliance Home office (Morrisville, North Carolina), at minimum one day a week, as approved by their supervisor.
Responsibilities & Duties
Strategic Leadership and Planning
Develop and implement strategic plans for optimizing operations within the Department
Align department activities with organizational goals and priorities
Manage the Department budget and develop strategic plans for ongoing quality improvement
Team Management
Work with PODS to maintain and retain a highly qualified and well-trained workforce
Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes
Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements
Actively establish and promote a positive, diverse, and inclusive working environment that builds trust
Ensure all staff are treated with respect and dignity
Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members
Work to resolve conflicts and disputes, ensuring that all participants are given a voice
Set goals for performance and deadlines in line with departmental and organization goals and vision
Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development
Cultivate and encourage efforts to expand cross-team collaboration and partnership
Foster a culture of continuous improvement, accountability and collaboration
Department Operations
Identify opportunities for process improvement and automation in the Department and in cross functional workflows
Streamline workflows to enhanced efficiency and reduce errors
Oversee the development of processes and/or systems for claims and encounter related initiatives/programs, and/or regulatory changes/requirements
Oversee the development of membership eligibility for state enrollment and ensure adherence to State guidance
Direct monitoring of Medicaid eligibility requirements including any reports related to member updates as determined by staff
Stay abreast on all regulatory and/or contractual changes, communicating changes to appropriate departmental staff and other departments
Direct the development and maintenance of policies and procedures in relation to claims, encounters and enrollment in response to regulatory and business updates and communicate revisions to appropriate staff
Collaboratively work with other departments to oversee Health Plan changes in ACS as it relates to service codes and benefit plans to ensure the accuracy of the system configuration and claims/encounter processing
Oversee the development and monitoring of Key Performance Indicators for Claims Management
Systems Improvement and Innovation
Oversee the development of new claims system for the purposes of future integration by monitoring the implementation of changes needed and continued meetings with internal staff
Lead efforts related to identifying and implementing short and long range goals for enhancement of claims business development efforts with a continuous focus on optimization and quality control
Partner with other departments, such as IT and Care Management, to define project parameters on claim adjudication improvements and regulatory report requirements
Analytics and Reporting
Monitor analytics to ensure service, quality, and business goals are achieved
Communicate and report effectively claims reports/ metrics and program updates to Executive Leadership and committees as required
Communicate and report effectively to Leadership, staff, and providers as needed on changes to claim system and preparation for Tailored Plan
Oversee CDW reporting to ensure compliance with state rules and timeframes, review and monitor results and provide quarterly updates to CFO
Internal and External Communication
Provide timely and accurate reports to Alliance leadership, Board members, providers, the community, staff and stakeholders as needed about claims and encounters
The SVP of Claims Management represents the organization in various state forums, in meetings, with stakeholders and providers
Minimum Requirements
Education & Experience
Bachelor’s degree from an accredited college or university in Business Administration, Health Administration, or related field and seven (7) years of progressive experience in Claims processing with a minimum of three (3) years of supervisory experience.
Or
Master’s degree from an accredited college or university in Business Administration, Health Administration, or related field and five (5) years of progressive experience in Claims processing with a minimum of three (3) years of supervisory experience.
Specific experience must include handling Medicaid, and Medicare healthcare claims processing.
Knowledge, Skills, & Abilities
Knowledge of regulatory requirements such as Title 42 Code of Federal Regulations (CFR) Part §422
Knowledge of CMS claims standards or contractual provisions on claims processing
Knowledge of Professional and Institutional billing, ICD-10/CPT/HCPCS coding, claims processing
Expertise in medical claims systems platforms
Knowledge of third party coordination of benefit expectations
Ability to complete and analyze IBNR and claims data
Detail oriented and ability to multi-task and able to meet frequently changing work demands
Excellent verbal and written communication skills and the ability to effectively collaborate with other departments in the successful resolution of operational issues
Strong leadership skills in the areas of staff development and performance improvement with demonstrated results
Ability to foster a cohesive working environment
Must be proficient in Microsoft Word, Excel and Outlook
Subject matter expertise and familiarity with Medicare and Medicaid requirements for encounters and full compliance
Extensive knowledge of all claims operations and medical claims processing—professional, pharmacy, and facility claims
Must possess strong problem-solving, project management, negotiation and leadership skills
Employment for this position is contingent upon a satisfactory background check and credit check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range
$138,735.00 to $233,526.00/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
