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Director, Claims

Montebello, CA 90640

Posted: 01/14/2025 Employment Type: Contract To Hire Job Category: Accounting & Finance Job Number: 627587 Country: United States Is job remote?: No

Job Description

Job Title: Claims Director
Contract – to – Hire
Onsite - Montebello, CA 90640
Must Have:
  • Bachelor’s degree or equivalent.
  • 8+ years in managed care Health Care Claims management.
  • 2+ years of supervisory experience.
  • Thorough knowledge of Managed Care regulations.
  • Proficiency in Microsoft Office and Excel
  • Knowledge of healthcare reimbursement, CPT and ICD-9 coding, and medical terminology.
Pluses:
  • EZCAP experience preferred.
Job Summary: The Director, Claims position has overall responsibility and accountability for all aspects of claims operations while effectively and efficiently delivering and enhancing the claims processing experience. This position is responsible for overseeing the daily claims, including timely and accurate processing of specialty claims for managed care members. The Director will leverage experience and integrate various components of cross-functional business decisions to continuously improve claims’ processes and procedures. This position oversees the claims inventory by setting, evaluating, and monitoring the claims inventory baseline and examiner productivity metrics to ensure the timely and accurate processing of claims in compliance with regulatory requirements and organizational expectations. This position will participate in various forums, company initiatives, and other internal/external workgroups to support Claims integrity. Directs all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Additional responsibilities include supervision and training of department staff, compliance with health plan and governmental regulations and standards, coordinating and overseeing health plan audits, and generations of management reports for fiscal and productivity analysis.
Essential Duties:
  1. Oversee Claims Operations and ensure regulatory compliance.
  2. Provide guidance on Claims Integrity efforts.
  3. Develop and manage relationships with managed care service providers.
  4. Collaborate with various stakeholders and staff to resolve issues impacting Claims quality.
  5. Implement plans to improve Claims processes.
  6. Participate in projects, committees, and audits.
  7. Define processes and workflows for the Claims Department.
  8. Serve as Subject Matter Expert on managed care contracts.
  9. Lead teams to improve claims data and payment accuracy.
  10. Direct and mentor staff, ensuring effective claims processing.
  11. Ensure compliance with health plan claims requirements.
  12. Manage member and provider inquiries.
  13. Support contracts administration with payment interpretation.
  14. Develop automation processes to improve accuracy and efficiency.
  15. Track and report on quality and efficiency improvements.
  16. Maintain department policies and procedures.

 

The staffing industry has seen an increase in people falsely representing themselves as recruiters to gather personal information from job seekers. For your safety, do not provide sensitive data to anyone you have not spoken with thoroughly, never provide banking information during the application process and always double check the email address of the Recruiter to ensure it’s from an official Planet domain (@theplanetgroup.com, @theplanetforward.com, @planet-technology.com, @planet-pro.com, @planetinteractive.com, @pfes.com, @launchcg.com, @planet-pharma.com, @planet-healthcare.com) - and not a domain with an alternative extension like .net, .org or .jobs.

The Planet Group and our companies are equal opportunity employers. It is our practice not to discriminate against any employee or applicant based on any criteria, condition or basis protected by laws or regulations in the locations where we do business. All qualified applicants are encouraged to apply. We celebrate diversity and are committed to providing an environment of mutual respect. We believe that diversity, equity and inclusion enable us to better meet our mission and values while serving our clients across the globe. If you have a disability or handicap and would like us to accommodate you in any reasonable way, please inform your recruiter, or contact us, so that we can discuss the appropriate alternatives available.

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About Montebello, CA

Ready to embark on a career journey in the vibrant city of Montebello, California? This diverse and thriving community offers a plethora of job opportunities across various industries, from healthcare to technology and beyond. Located in Los Angeles County, Montebello boasts a rich cultural heritage, stunning views of the San Gabriel Mountains, and easy access to popular attractions like the Commerce Casino and the Shops at Montebello. Indulge in the local cuisine, enjoy performances at the Montebello Barnyard Zoo or take a stroll through Grant Rea Park. Find your next career move in this dynamic city, where endless possibilities await. Explore our job listings today and discover the exciting opportunities Montebello has to offer!
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