Health Plan of San Joaquin/Mountain Valley Health Plan · 22 hours ago
Director, Claims
Modesto, CA
Full-time
Hybrid
Mid Level
$167K/yr - $248K/yr
4+ years expHealth Plan of San Joaquin is now hiring an experienced and dedicated Director, Claims. The role involves developing and overseeing the implementation of strategic and operational objectives related to claims administration, ensuring compliance with regulations, and leading a team to enhance claims processing efficiency.
Health CareHealth InsuranceInsurance
Responsibilities
Identifies, develops, plans and executes business strategies, collaborating with executives, peers and others to ensure effective integration; directs the development and implementation of department goals and actions plans
Oversee routine and ad hoc internal and external audits and direct the development, implementation and monitoring of corrective action plans
Develops and monitors quantitative and qualitative analyses of claims data, trends and forecasting; implements appropriate interventions
Oversees preparation for and participate in regulatory audits and external review activities; develops and monitors corrective actions plans
Develops or directs the development of policies; ensures the development and implementation of appropriate companion procedures, guidelines and other documents
Proactively Identifies and develops strategies to address issues and trends with claims processing
Ensure compliance with applicable laws and regulations
Oversee the development, implementation and maintenance of the appropriate and required data, records, reports and other documentation
Identifies and oversees the implementation of process improvement strategies
Leads the development, implementation and maintenance of best practice methodology, including metrics; ensures dissemination and understanding among stakeholders
Anticipates technology needs; oversees development and implementation; collaborates to improve or upgrade current technology solutions
Develops and manages department budget, implements appropriate interventions
Promote and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values
Hires, develops and retains, and ensures that subordinate managers hire, develop and retain an adequate and competent staff
Other duties as required
Qualification
Required
Expert knowledge of and ability to apply and facilitate the adoption of best practices
In-depth knowledge of the principles and practices of claims operations
In-depth knowledge of health plan functions and interactions and their impact on claims
In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs as they relate to claims
In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions, and industry standard payment practices
In-depth knowledge of claims processing systems
Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions
Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems
Decision quality: Makes good and timely decisions that keep the organization moving forward
Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies
Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results
Ability to create relevant department objectives, and create, execute and monitor business plans
In-depth knowledge of internal and external audit processes, and the ability to effectively implement and maintain them
Demonstrated ability to develop and manage realistic budgets
Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals inside and outside of the HPSJ
Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of HPSJ
Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, and maintain effective, high-performance teams
Strong assessment and analytical skills, including the ability to synthesize, distill concepts, draw conclusions and identify implications
Build networks: Effectively build formal and informal relationship networks inside and outside of the organization
Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics
Persuades: Uses compelling arguments to gain the support and commitment of others
Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities
Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals
Ensures accountability: Holds self and others accountable to meet commitments
Drives results: Consistently achieve results, even under tough circumstances
Strong project management skills, including the ability to manage organizational-wide projects to successful conclusions
Manages ambiguity: Operates effectively, even when things are not certain, or the way forward is not clear
Strong knowledge of change management theory, with ability to anticipate and implement effectively
Strong customer service skills
Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ's strategy, vision, mission and values
Ability to supervise staff in a manner that maximizes employee performance and business results, which includes very strong coaching/counseling skills and ability to function as a mentor
Ability to speak and be understood in English
Ability to handle confidential information with appropriate discretion
Bachelor's Degree or related fields or equivalent experience
At least four years as a manager in a health plan overseeing all aspects of claims administration
At least six years Medi-Cal claims experience
Supervisory experience in a healthcare setting
Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability
Preferred
In-depth knowledge of QNXT core processing system
Master's degree
Benefits
Competitive salary
Robust and affordable health/dental/vision with choices in providers
Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
Two flexible spending accounts (FSAs)
Employer-Paid Term Life and AD&D Insurance
Employer-Paid Disability Insurance
Employer-Paid Life Assistance Program
Health Advocacy
Supplemental medical, legal, identity theft protection
Access to exclusive discount mall
Education and training reimbursement in addition to employer-paid elective learning courses.
A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
Company
Health Plan of San Joaquin/Mountain Valley Health Plan
Health Plan of San Joaquin/Mountain Valley Health Plan (not-for-profit health plan) is the leading Medi-Cal managed care provider in San Joaquin in Stanislaus Counties, now serving Medi-Cal members in Alpine in El Dorado Counties.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Lizeth Granados
Chief Executive Officer
Michelle Tetreault
Chief Financial Officer | Interim Chief Executive Officer (2019)
Company data provided by crunchbase