Sr. Director - Claims Operations

United States

Job Description

Leadership oversight and budget management of the operational teams responsible for the implementation and maintenance of client member data, and the quality assurance testing and implementation of claims modules. Partner with IT or external vendor to define claims adjudication project prioritization and IT roadmap. Manage performance and service results through clearly defined Service Level Agreements (SLAs). employees’ skills evaluate performance and provide feedback and oversee resolution of employee relations issues. Workforce and budget planning including resource forecast modeling for peak and non-peak periods. Recruit, attract, develop, motivate and manage a high caliber of employees; train employees on products, policies and procedural changes and effectively orient new employees.
  • Provides management oversight of the operational teams responsible for the implementation and maintenance of client member data. Business owner responsible for the management and oversight of client and member data exchange for Prior Authorization, Claims History and Accumulator data loads.  Act as Claims work stream leader for new client implementations including client facing responsibilities related to requirements gathering to support the on boarding of new client member data and paper claims processing. Drive quality improvement efforts and initiatives that provide scalability for growth.
  • Manages the relationship with IT or external vendor to define claims adjudication project prioritization and IT roadmap. Review and track project resource capacity, resource allocation, and status of projects.
  • Management oversight of operational teams responsible for paper claims processing, issue research/resolution and leverage departmental metrics to measure and monitor performance results.  Provide strategic support and coaching to leadership team and team members.  Build Claims and Operations team; work to develop employ employees’ skills, evaluate performance and provide feedback, and oversee resolution of employee relations issues.
  • Recruits, attracts, develops, motivates and manages a high caliber of employees; train employees on products, policies and procedural changes and effectively orient new employees.
  • Represents Claims and Operations capabilities in RFP inquiries and sales finalist presentations.
  • Acts as Claims and Operations business owner; represent business needs for departmental system applications.
  • Collaborates with client facing teams to execute on client requests that impact operational tools.
  • Manages key control points and ensures that work is tracked accurately and signed off on by the appropriate parties. Responsible for monitoring and maintaining a detailed tracking mechanism to log and track requests for benefit changes and upgrades to the claims processing system.
  • Leverages departmental metrics to measure, monitor, and control quality results. Work with client facing business partners to ensure improvement opportunities are addressed. Report performance results to Sr. Leadership; conduct ongoing review of data to identify opportunities to improve service levels.
  • Provides strategic support and coaching to leadership team and team members.
  • Works to develop employees’ skills, evaluate performance and provide feedback, and oversee resolution of employee relations issues.
  • Manages workforce and budget planning including resource forecast modeling for new business.

General Job Information

Title

Sr. Director - Claims Operations

Grade

29

Job Family

Operations Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

6/11/2019

Date Requisition Created

5/21/2019

Work Experience

Claims, Management/Leadership, Operations

Education

Bachelors: Business Administration (Required)

License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements

Responsibilities

15+ years Operational Leadership experience in Healthcare Industry

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.