Director, Medical Payment Operations

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Provide leadership and direction to the Medical Payments and Bill Review Team across all four brands. Act as a primary, independent, visionary, and proactive authority; providing in-depth analysis of medical payments areas including statistical, industrial, and regulatory perspectives. Provide operational consistency and integrity to claims and the medical payments processes. Serve as a technical expert with regard to department operations. Collaborate with Brand Leadership, Corporate Claims, and OGC/Compliance to ensure timely and accurate medical payments in compliance with statutory and regulatory requirements.

Represent AF Group in/at industry functions with regulators, vendors, and peer groups; WCRI, NCCI, etc. Maximize efficiency and savings in M  and with Vendor Management and Pharmacy Programs.

• Plan, direct, manage and evaluate the day-to-day operations and workflow of production, claims management and customer teams.
• Consult with Claims, Corporate Claims, Government Affairs and OGC leadership across the organization to provide necessary support and feedback to ensure most productive, efficient, compliant, and cost-effective ways to conduct business.
• Serve as lead contact and oversee the management of the Medical Bill Review software partner and any outside review vendors.
• Attend industry functions with regulators, vendors and peer groups, to represent AF Group to ensure best in class medical bill review program.
• Responsible for the development, implementation and maintenance of the Medical Bill Review Quality Assurance Program.
• Responsible for staying current on changes in workers’ compensation statutes and cases; medical fee schedules and reimbursement methodologies as well as subrogation and recovery laws and procedures.
• Conduct and/or direct advanced statistical analysis and research related to medical reimbursements, claims and claims operations.
• Oversee and manage strong, professional working relationships with state regulatory agencies, as well as vendors, by serving as a key contact. This includes ensuring quality communication and exceptional work product.
• Collaborate with appropriate parties in root cause analysis and minimization of delays, surcharges, fines, and penalties.
• Participate in development of annual departmental budget.
• Establish and monitor KPIs and SLAs for departmental success and compliance.

• Bachelor’s degree in insurance, business or a related field required. Certification or progress toward certification is highly preferred and encouraged.
• Eight years experience of progressive responsibility in a claims medical bill review environment with demonstrated technical knowledge.
• Minimum three years of demonstrated leadership ability in a claims or medical bill review environment required.

• Working knowledge of workers' compensation statutes and fee schedules, medical reimbursement methodologies, filing procedures, settlement options, claims processes, and medical terminology.
• Demonstrated leadership ability.
• Ability to bridge IT requirements and departmental needs.
• Excellent analytical skills to identify improvement needs and develop solutions.
• Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information and respond to questions as appropriate.
• Strong interpersonal skills and the ability to negotiate while creating and maintaining mutually beneficial relationships with working partners.
• Ability and proficiency in the use of computers and company standard software, including advanced knowledge in Excel, and other corporate databases.
• Ability to establish workflows, manage multiple projects and meet necessary deadlines.
• Ability to comprehend the consequences of various problem situations and address them or refer them for the appropriate decision-making. Independently resolves most problems.
• Ability to read, analyze, interpret and effectively present budgetary and/or cost information and respond to questions as appropriate.
• Ability to maintain confidentiality.