Claims Director, Denver Health Medical Plan
We are recruiting for a Claims Director, Denver Health Medical Plan to join our team! We are here for life's journey.
Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all:
Humanity in action, Triumph in hardship, Transformation in health.
Department Managed Care Administration Remote opportunity for residents of Colorado, Illinois, Kentucky, Ohio, Pennsylvania, South Carolina, Texas, Utah, Virginia, Washington, and Wisconsin.
Job Summary The Director of Claims Operations develops, directs, implements, and oversees the management and payment of claims for all lines of business at Denver Health Medical Plan.
Develops and implements all related processes and manages the external benefit configuration vendor.
Responsible for managing the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with contracted fee schedules and covered benefits as specified.
Hires, supervises, and develops all staff.
Actively participates as a member of the Plan's Operations Management Team.
Essential Functions:
Claims Operations Management Manages and oversees the integrity of the claims management process, ensuring that all daily operations adheres to the rules, regulations, and contractual requirements of CMS, CO DOI, contracted and non-contracted providers.
Ensures the contractual performance of Business Management Services (BMS), including appropriate turnaround time, accuracy, claims inventory audit, and issue resolution.
Works closely with Information Systems and Provider Relations & Contracting to ensure the integrity of the QNXT system, including appropriate development and configuration.
Works closely with Utilization Management to implement and modify authorization requirements to ensure appropriate adjudication.
Develops, modifies, reviews, and implements all policies and procedures for pricing changes, subrogation, contractual modifications, and adjustments.
Works closely with Compliance to monitor and detect potential fraud and abuse and ensure all operations remain in regulatory compliance.
Staff Management & Training Manage the daily operations of the Claims Operations staff, including hiring, training, supervising, evaluating, and developing the Claims Manager, two Business Care Analysts, and two Claims Processors.
Develop, review, and present reports on productivity and accuracy.
Develop comprehensive training programs and ensure acquisition of knowledge related to all claims policies and procedures.
Determine department operating procedures and expedite workflow; assigns duties and reviews work.
Promotes positive interpersonal (customer) relationships with fellow employees, physicians, patients and visitors.
Treats these individuals with courtesy, dignity, empathy and respect; consistently displays courteous and respectful verbal and non-verbal communications.
Adheres to, complies with and demonstrates support for the mission and values of Denver Health.
Supports and adheres to the Denver Health Values of Trust, Respect, & Excellence and the Standards of Behavior.
Ensures confidentiality of patient information by creating and maintaining a secure and trusting environment by not sharing information learned on the job, except when necessary in the performance of the job responsibilities or to improve a patient's care.
Education:
Bachelor's Degree Required Work
Experience:
Five to seven years of claims management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines, Required and 1-3 years Strong experience in managing claims system development, configuration, and maintenance.
Required and 1-3 years Experienced in managing claims processing for Medicare, Medicaid, CHP+, Large Group Commercial, and Healthcare Exchange.
Licenses:
Knowledge, Skills and Abilities:
Demonstrated track record in creating approaches, policies, and procedures to ensure effectiveness of the claims payment and adjudication process at a health plan.
Solid system development and evaluation abilities, effective leadership and management, and outstanding written and oral communication skills are required.
Experience and proficiency with Trizetto QNXT is highly desired.
Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services (CMS) and the Colorado Department of Health Care, Policy & Financing (HCPF) is required.
Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA.
Knowledge of bundled payments, risk-sharing, and provider capitation is essential.
Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems.
Able to perform effectively in a leadership role and evaluate processes for efficiency.
Experienced in supervising staff and ensuring key tasks and goals are met on a timely basis.
Remote opportunity for residents of Colorado, Illinois, Kentucky, Mississippi, New Hampshire, Ohio, Pennsylvania, South Carolina, Texas, Utah, Virginia, Washington, and Wisconsin Shift Days (United States of America) Work Type Regular Salary $141,000.
00 - $218,500.
00 / yr Benefits Competitive pay Outstanding benefits Education opportunities Shared leadership and advancement opportunity State-of-the-art facilities Immediate retirement plan matching Professional clinical advancement program Participation in evidence-based projects Public Service Loan Forgiveness (PSLF) eligible employer National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer Our Values Respect Belonging Accountability Transparency All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.
As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured.
Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
Denver Health values the unique ideas, talents and contributions reflective of the needs of our community.
For read more about our commitment to diversity visit:
https:
//www.
denverhealth.
org/for-professionals/careers/diversity-and-inclusion Recommended Skills Auditing Business Management Communication Confidentiality Content Management Courtesy Estimated Salary: $20 to $28 per hour based on qualifications.
Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all:
Humanity in action, Triumph in hardship, Transformation in health.
Department Managed Care Administration Remote opportunity for residents of Colorado, Illinois, Kentucky, Ohio, Pennsylvania, South Carolina, Texas, Utah, Virginia, Washington, and Wisconsin.
Job Summary The Director of Claims Operations develops, directs, implements, and oversees the management and payment of claims for all lines of business at Denver Health Medical Plan.
Develops and implements all related processes and manages the external benefit configuration vendor.
Responsible for managing the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with contracted fee schedules and covered benefits as specified.
Hires, supervises, and develops all staff.
Actively participates as a member of the Plan's Operations Management Team.
Essential Functions:
Claims Operations Management Manages and oversees the integrity of the claims management process, ensuring that all daily operations adheres to the rules, regulations, and contractual requirements of CMS, CO DOI, contracted and non-contracted providers.
Ensures the contractual performance of Business Management Services (BMS), including appropriate turnaround time, accuracy, claims inventory audit, and issue resolution.
Works closely with Information Systems and Provider Relations & Contracting to ensure the integrity of the QNXT system, including appropriate development and configuration.
Works closely with Utilization Management to implement and modify authorization requirements to ensure appropriate adjudication.
Develops, modifies, reviews, and implements all policies and procedures for pricing changes, subrogation, contractual modifications, and adjustments.
Works closely with Compliance to monitor and detect potential fraud and abuse and ensure all operations remain in regulatory compliance.
Staff Management & Training Manage the daily operations of the Claims Operations staff, including hiring, training, supervising, evaluating, and developing the Claims Manager, two Business Care Analysts, and two Claims Processors.
Develop, review, and present reports on productivity and accuracy.
Develop comprehensive training programs and ensure acquisition of knowledge related to all claims policies and procedures.
Determine department operating procedures and expedite workflow; assigns duties and reviews work.
Promotes positive interpersonal (customer) relationships with fellow employees, physicians, patients and visitors.
Treats these individuals with courtesy, dignity, empathy and respect; consistently displays courteous and respectful verbal and non-verbal communications.
Adheres to, complies with and demonstrates support for the mission and values of Denver Health.
Supports and adheres to the Denver Health Values of Trust, Respect, & Excellence and the Standards of Behavior.
Ensures confidentiality of patient information by creating and maintaining a secure and trusting environment by not sharing information learned on the job, except when necessary in the performance of the job responsibilities or to improve a patient's care.
Education:
Bachelor's Degree Required Work
Experience:
Five to seven years of claims management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines, Required and 1-3 years Strong experience in managing claims system development, configuration, and maintenance.
Required and 1-3 years Experienced in managing claims processing for Medicare, Medicaid, CHP+, Large Group Commercial, and Healthcare Exchange.
Licenses:
Knowledge, Skills and Abilities:
Demonstrated track record in creating approaches, policies, and procedures to ensure effectiveness of the claims payment and adjudication process at a health plan.
Solid system development and evaluation abilities, effective leadership and management, and outstanding written and oral communication skills are required.
Experience and proficiency with Trizetto QNXT is highly desired.
Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services (CMS) and the Colorado Department of Health Care, Policy & Financing (HCPF) is required.
Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA.
Knowledge of bundled payments, risk-sharing, and provider capitation is essential.
Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems.
Able to perform effectively in a leadership role and evaluate processes for efficiency.
Experienced in supervising staff and ensuring key tasks and goals are met on a timely basis.
Remote opportunity for residents of Colorado, Illinois, Kentucky, Mississippi, New Hampshire, Ohio, Pennsylvania, South Carolina, Texas, Utah, Virginia, Washington, and Wisconsin Shift Days (United States of America) Work Type Regular Salary $141,000.
00 - $218,500.
00 / yr Benefits Competitive pay Outstanding benefits Education opportunities Shared leadership and advancement opportunity State-of-the-art facilities Immediate retirement plan matching Professional clinical advancement program Participation in evidence-based projects Public Service Loan Forgiveness (PSLF) eligible employer National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer Our Values Respect Belonging Accountability Transparency All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.
As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured.
Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
Denver Health values the unique ideas, talents and contributions reflective of the needs of our community.
For read more about our commitment to diversity visit:
https:
//www.
denverhealth.
org/for-professionals/careers/diversity-and-inclusion Recommended Skills Auditing Business Management Communication Confidentiality Content Management Courtesy Estimated Salary: $20 to $28 per hour based on qualifications.
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