Director, Claims Operations - PHH

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree in Business Administration, Healthcare Administration or a related field AND Ten (10) years of experience working in Claims Operations or Healthcare Environments.

OR

2. Associate's degree in Business Administration, Healthcare Administration, or related field AND Twelve (12) years of experience working in Claims Operations or Healthcare Environments.

EXPERIENCE:

1. Four (4) years of management experience in Claims Operations, including recent experience managing people, process and technology to achieve desired operational outcomes.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Epic Tapestry.

EXPERIENCE:

1. Medicare and/or Medicaid Claims Operations.

2. Experience working in a start-up business environment.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Participates in business planning and strategy sessions to improve health plan design and develop business requirements to support system implementation.

2. Develops and manages a staffing plan and budget for Claims Department.

3. Hires and manages an engaged workforce to deliver exceptional customer service and quality.

4. Sets team direction, resolves issues and provides mentoring and guidance to team.

5. Lead initiatives to improve claims processing efficiency and accuracy, reducing operational costs and improving member satisfaction.

6. Ensure compliance with all regulatory requirements and payer policies across claims operations.

7. Design and operationalize KPI and performance management frameworks to monitor claims health and support executive decision-making.

8. Partner with Technology teams to shape claims platform configuration and optimization.

9. Develop, implement, and monitor process improvement initiatives across claims and provider operations.

10. Deep understanding of claims lifecycle, EDI transactions, payment integrity, provider data, appeals/grievances, and audit/compliance (CMS, HIPAA, NCQA, state regs).

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Excellent written and oral communication.

2. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

3. Attention to detail.

4. Proficiency with Microsoft Office.

5. Technical and operational competency to support the implementation and refinement of core administration platform.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.