Director - Claims

Director Of Claims And Encounters

The Director Of Claims And Encounters provides strategic leadership, fiscal accountability and operational excellence for the Presbyterian Health Plan (PHP) Claims Operations and Encounter Resolution teams. This leader is responsible for directing the operations of the Claims Department for Commercial / ASO, Medicare and Medicaid products, to ensure that all functions related to claims receipt, processing and payment are performed within the established quality and quantity standards. You will lead the encounters resolution team and be the leader responsible for encounters completeness and facilitating maximized Medicaid rate setting. This leadership role is accountable to drive execution of operational strategy across responsible areas through accurate, timely and efficient delivery of production activities that incorporate market-leading practices.

In addition to operational, this leadership role is accountable to champion and execute on the prioritized deployment of Auto-Adjudication methodologies, use of Robotic Process Automation (RPA / Bots), increased first pass and overall encounter acceptance and process simplification to achieve operational optimization and cost effectiveness. This role will lead department strategic objectives and have responsibility to achieve measurable gains in reduced cycle times and improve functional effectiveness in departmental processes. This role will make use of deep claims and encounters expertise to improve the member and provider experience.

This position is intended to be conducted in the state of New Mexico.

Qualifications

• Bachelors degree in Finance, business, healthcare or related field.
• MBA preferred.
• At least 10 years of healthcare specific operational leadership experience with a focus on Health Plan Claims Operations
• At least 5 years of experience leading in a similarly complex function.
• Ability to assimilate business group strategy / objectives to develop appropriate programs and solutions that support business goals.
• Demonstrated experience navigating, influencing and leading within a highly matrixed environment.
• Advanced experience working on complex analytical projects with diverse teams and developing data driven and outcome-based initiatives to improve business decision making and operational efficiencies.
• Strong understanding of customer experience and lifecycle, as it relates to experiencing health plan benefits.
• Deep understanding of operations in the Health Care industry and a strong acumen of business processes, including operations, delivery models and revenue models.
• Content knowledge related to program outcomes evaluation, BI tools (e.g., BO), data visualizations tools (e.g., Tableau).
• Ability to summarize and clearly communicate ideas and processes, both orally and in writing.
• Skills :
• Anticipating & Addressing Customer Needs
• Educating Employees, Customers & Transferring Knowledge
• Functioning as an Effective Contingent Member
• Diagnosing & Resolving Complex Problems
• Acquiring & Applying Superior Skills to achieve Quality Outcomes
• Functioning as an Effective Team Member
• Ability to present to various audiences

Responsibilities

Benefits

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

About New Mexico

New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA / EOE / VET / DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer For This Position Is Up To

USD $77.90 / Hr.

Compensation Disclaimer

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.