Director of Claims

Direct overall planning, development, and operations of the claims management system. Provide recommendations to executive leadership team and implement plans regarding the claims management system.

• Provide strategic input on claims processing and payment decisions within the Claims Management (CM) Department.
• Participate in the development of the CM budget.
• Schedule and supervise internal and external audits related to claims issues and develop reports on audit findings and recommendations.
• Manage day-to-day workflow and operations of claims management.
• Establish policies and procedures for claims processing, including standards of performance, claims auditing, and other measurement techniques.
• Supervise department employees, including hiring and performance management.
• Review settled claims to ensure compliance with organizational practices and procedures.
• Verify and analyze data used in setting claims to ensure accuracy and compliance with procedures.
• Report on over payments, underpayments, and irregularities.
• Consult with legal counsel on claims requiring litigation.
• Ensure compliance with CPT and ICD requirements.
• Analyze account details and respond to inquiries regarding claims payment or status.
• Assist with pre-claim system edits and provide guidance on coding issues.
• Support medical and behavioral health providers with coding and billing documentation.
• Participate in encounter reporting and ensure accurate coding for various programs.
• Review billing encounter forms annually to update codes.
• Provide ongoing orientation to new employees and clinical providers on coding, billing documentation, and compliance.
• Review provider medical record documentation and employee performance to monitor compliance with coding and billing regulations.
• Implement compliance plans for coding and billing accuracy and identify risk areas for correction.
• Assist with educational programs for providers and staff, including responses to provider inquiries.
• Participate in various committees and meetings as necessary, including the OCHN Compliance Committee.
• Chair the OCHN Procedure Code Workgroup.
• Maintain current industry knowledge and attend conferences for professional certifications.
• Ensure compliance with OCHN’s Health and Safety Policies.
• Oversee the administration, configuration, and maintenance of the claims adjudication system.
• Direct review and implementation of business process changes impacting the claims system.
• Establish partnerships with the Senior Leadership Team to ensure claims system accuracy.
• Lead compliance audits and remediate identified issues.
• Perform any other related duties as assigned.

• A bachelor’s degree in business administration or a related field.
• Master degree in a relevant discipline preferred.

• Must have RHIT or CPC certification.
• Note:
  
  If the selected employee does not have this certification, that employee must receive the certification within six (6) months of the date of hire to maintain employment.

• Minimum of five (5) years managerial/supervisory experience with at least five (5) years of professional experience in outpatient, Medicare and Medicaid, computerized and manual billing for third party payors.

• Demonstrated effective interpersonal skills.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated effective negotiation skills.
• Demonstrated effective written and oral communication skills.
• Demonstrated effective computer skills.
• Demonstrated effective project management skills.

• Ability to recognize and analyze complex operational/administrative or fiscal problems, and to…