Director, Claims

With a mission to heal and inspire the human spirit, Inland Empire Health Plan (IEHP) is one of the top 10 largest Medicaid health plans and the largest not-for-profit Medicare-Medicaid plan in the country. In its 29th year, IEHP supports nearly 1.6 million members who are enrolled in Medicaid and has a growing network of over 8,000 providers and nearly 4,000 Team Members (Employees). Through dynamic partnerships, award-winning service, and a tradition of quality care, IEHP is fully committed to its Mission, Vision, and Values.

IEHP has consistently achieved outstanding employee engagement scores from their 4,000+ Team Members and was most recently recognized and awarded the designation of ‘Great Place to Work’ for a third year in a row!

About the Position:

Reporting to the Senior Director, Claims, the Director, Claims is responsible for the direction and oversight of all medical claims processing, provider disputes & appeals, quality assurance, and training activities. Additional responsibilities include ensuring regulatory compliance, strategic planning, and staff development.

Responsibilities:

• Ensure all claims, appeals and disputes are accurately handled within Federal and State regulatory requirements
• Oversight of quality assurance audits and initiatives focused on payment accuracy and streamlined processes
• Oversight of all department training activities
• Primary department representation for internal/external claim audits and regulatory appeals and inquiries
• Responsible for ensuring regulatory reporting and fulfilling corrective action plans for identified deficiencies
• Coordinates department purchasing needs and originates RFP’s and RFQ’s for needed services
• Prepares department budget and staffing plan
• Ensures all department policies and provider manual claim policies are maintained
• Interacts with other IEHP departments to collaborate on key initiatives, issue resolution and Lean activities

Experience Requirements:

• Five (5) years healthcare administration experience required
• Four (4) or more years in a leadership capacity required
• Two (2) years of experience with an HMO or managed care experience required
• Medi-Cal/Medicaid claims experience required and Medicare/DSNP/ACA Exchange experience preferred

Educational Requirements:

• Bachelor’s degree in business administration, accounting, or healthcare from an accredited institution required
• Master’s degree from an accredited institution preferred

Knowledge & Skills:

• Solid understandings of rules and regulations governing Medi-Cal benefits and claims adjudication practices and procedures
• Principles and techniques of supervision and training
• Microcomputer literacy preferred

Commitment to Team Culture:

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Salary range: $154,128.00 – $254,300.80 based upon related/relevant experience and internal equity.