Director, Legal Operations

Legal Operations Division Manager

Responsibilities

Provides operational oversight and direction for the Legal Operations division, which includes Appeals, Workers' Compensation, Liens, Fraud and Abuse, Compliance, and Contract Administration. Provides leadership to ensure divisional goals are strategically planned and developed, thoughtfully implemented, and successfully achieved in accordance with departmental and fund goals and objectives. Provide strategic leadership for the Fraud, Waste, and Abuse Operations, ensuring effective management and oversight. Oversee and guide the Compliance Audit Unit in its critical role of managing the Internal Audit and Internal Control Audit Plan for the Funds. Ensure that comprehensive audit strategies are developed and implemented effectively, fostering a culture of transparency and accountability throughout the organization. Oversee all activities related to Contract Administration including reviewing and approving all contracts, vendor agreements, and RFPs as needed. Ensure legal and operational concerns are addressed and contracts contain appropriate language to protect the Fund. Draft and review proposed language changes for Summary Plan Description (SPD), other legal documents, minutes and communications prepared by the Fund; ensure they are accurate, in compliance with relevant laws and regulations. Lead a multi-departmental team that researches, reviews, and resolves member appeals; interprets and explains health plan benefits, policies, and procedures to members and providers. Partner with the General Counsel's Office to comprehensively review relevant appeal information, ensuring compliance with Summary Plan Descriptions, ERISA, DOL and other regulatory compliance. Implement strategies to administer the Fund's Right to Reimbursement and Subrogation in Third Party Lien and No-Fault Cases, as well as, recovery of benefits paid by the Fund in Workers' Compensation Cases. Lead and mentor direct reports. Evaluate performance, monitor achievement of goals and departmental performance standards; identify areas for development; create improvement plans, coach and counsel as appropriate. Responsible for area budgets; analyze, prepare data, reports, and implement operating and expense controls. Perform additional duties and projects as assigned by management.

Qualifications

Juris Doctor (JD) degree or equivalent combination of relevant education and experience required. Minimum of eight (8) years of relevant senior-level experience in healthcare administration or health claims operations, including 6 years of supervisory experience required. Excellent knowledge of Department of Labor (DOL), Employee Retirement Income Security Act (ERISA) Health Insurance Portability and Accountability Act (HIPAA), and Consolidated Omnibus Budget Reconciliation Act (COBRA) regulatory bodies. Knowledge of Taft-Hartley Welfare Trust Funds and their relationships to the Union, Employers and Members they represent. Strong strategic planning skills a must; excellent analytical, attention to detail, and problem-solving skills. Good negotiation, communication, and interpersonal skills; Good knowledge of Microsoft Office Suite. Demonstrated leadership skills and experience driving organizational projects. Works under minimal supervision with extensive latitude for initiative and independent judgment. Must have the ability to plan, coordinate, and direct the work of subordinate staff engaged in various professional, technical, and clerical functions.