Director Claims Configuration, New York, NY

Employer Healthfirst Inc.
Created 07/19/2021
Reference 1091549
Job Type Full Time
State NY
City New York
The Director Claims Configuration is responsible for directing and coordinating the configuration of plan designs across major Healthfirst platforms in collaboration with leaders from Product, Claims and Medical Management. The Director also leads a team of managers and analysts to ensure accurate, efficient and timely configuration of new or revised member benefits, clinical authorizations, claims editing, reference data, non-standard provider contracts and claim system functionality for all Healthfirst lines of business. The Director leads the cross-functional claims configuration coordination activities and stewards the authoritative source of claims business rules for all lines of business. The Director is an active participant in new product launches, go-to-market processes, and changes in medical policy that affect the administration of claims business rules across the company. Recognized as an influential leader, the individual at this level functions as a cultural ambassador and strategy driver for Healthfirst. He/she promotes and reinforces behavior that is consistent with Healthfirst's desired culture and fulfills his/her role in aligning Healthfirst's strategic initiatives with the desired organizational outcomes.

Duties & Responsibilities:
  • Define the Strategy, lead the development and execution of our claims configuration roadmap across departments, identify risks and manage interdependencies
  • Build and maintain the "authoritative source" of claims business rules and their administration for Healthfirst including all relevant aspects of plan design, medical policy and claims payment
  • Highlight and resolve inconsistencies between product design, claims payment and medical policy
  • Participate and support company-wide initiatives. Assess impact of issues and future direction of Healthfirst, and the upstream and downstream impact of processes and policies.
  • Drive flexible, repeatable and scalable claims configuration design and implementation processes with industry best-practices.
  • Work with internal and external parties to ensure claims business rules are well understood and administered appropriately
  • Actively support all Compliance and Regulatory requirements, both current and new, with appropriate policies, processes, reports, and audit support.
  • Additional duties as assigned.

Minimum Qualifications:
  • Bachelor's Degree from an accredited institution or equivalent work experience
  • Experience leading complex, technical, cross-functional programs and working with senior executives
  • Experience leading and managing technical and non-technical staff
  • Experience articulating complex issues for non-technical audiences
  • Knowledge of medical claims and adjudication procedures, including the application of medical policy (authorizations) guidelines, contract pricing and member benefits to claims processed.
  • Familiarity with regulatory frameworks governing health plan benefits in Medicare, Medicaid and commercial insurance markets
  • Experience influencing leaders, breaking down barriers and managing competing priorities

Preferred Qualifications:
  • Hands-on experience with commercial and government claims payment systems and administration
  • Knowledge or experience with high-complexity benefit design methods at major payers or delegated service providers
  • Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

Compliance & Regulatory Responsibilities: See Above

License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Minimum Qualifications:
  • Bachelor's Degree from an accredited institution or equivalent work experience
  • Experience leading complex, technical, cross-functional programs and working with senior executives
  • Experience leading and managing technical and non-technical staff
  • Experience articulating complex issues for non-technical audiences
  • Knowledge of medical claims and adjudication procedures, including the application of medical policy (authorizations) guidelines, contract pricing and member benefits to claims processed.
  • Familiarity with regulatory frameworks governing health plan benefits in Medicare, Medicaid and commercial insurance markets
  • Experience influencing leaders, breaking down barriers and managing competing priorities

Preferred Qualifications:
  • Hands-on experience with commercial and government claims payment systems and administration
  • Knowledge or experience with high-complexity benefit design methods at major payers or delegated service providers
  • Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

Compliance & Regulatory Responsibilities: See Above

License/Certification: NA

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