Employment Type: Full time Shift: Description: It is the role of the Director of Claims Operations & System Configuration to ensure that claims are administered in a manner that reflects correct payments for all network and non-network providers. Why MediGold? MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more. We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing. What we offer: Competitive compensation and benefits packages including medical, dental, and vision coverage Retirement savings account with employer match starting on day one Generous paid time off programs Employee recognition incentive program Tuition/professional development reimbursement Relocation assistance (geographic restrictions apply) Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day! Why Columbus? The nation's 14th largest city, Columbus, Ohio is one of the fastest growing major metropolitan areas in the Midwest – ranked #1 for population growth, #1 for job growth, #1 for wage growth, and #1 real estate market. And with a vibrant blend of professional sports, world-class attractions, creative cuisines, and a flourishing music and arts scene, you'll never be found wanting for entertainment and experiences to call your own in Columbus. Learn more at www.experiencecolumbus.com! About the job: The Director of Claims Operations and System Configuration directs the activities of all reporting positions in the Claims Operations, Claims System Configuration, and Provider Data Management departments, including the delegated (vendor) relationships for claims processing, to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achievement of cost objectives and service level goals; provider data management and related downstream processes; collaboration with all other Plan departments to ensure Plan goals are achieved and compliance with Centers for Medicare and Medicaid Services (CMS) guidelines are met. What you'll do: Establish standards of performance, including training, policies and procedures, claims auditing and other performance measurement techniques. Oversee all activities related to claims processing. Primary oversight and responsibility for delegated claims functions performed by third party vendor, including claims processing and fulfillment. Oversee the coordination of procedures for administering the various benefit plans and provider contracts with all interfacing systems. Audit contract set-up and recommend changes based on results. Audit Provider fee schedules and pay classes to ensure accuracy and correct payment. Responsible for implementing and auditing benefit changes as related to claims processing. Responsible for monitoring Medicare changes as they relate to claims payment and methodologies, benefits and coding and billing. Develop and implement cost control measures. Through auditing and internal reporting, proactively identify negative or positive trends and report to management with recommendations for change. Assist in responses to Provider inquiries. Participant on various committees as necessary and appropriate. Maintain current industry knowledge as necessary and appropriate for position. Oversight of the administration, configuration and ongoing maintenance of the Mount Carmel Health Plan claims adjudication system. Directs the review of business process changes impacting the claims system. Directs the implementation and continuous improvement of claims adjudication system management policies, standards and processes. Establishes partnerships and works closely with the Senior Leadership Team to ensure claims system configuration accuracy; develop plans to address any potential system inaccuracies or configuration errors. Leads compliance audits and remediates issues identified as required. Meets population specific and all other competencies according to department requirements. What we're looking for: Preferred Education Requirement: Bachelor’s Degree Licensure Requirement: CPC or equivalent preferred. Experience: 8-10 years of Managed Care experience, preferably in Medicare Advantage. 5 plus years of previous management experience in office environment analyzing and developing office/production systems/procedures. Experience with Medicare and corresponding regulatory requirements preferred. Effective Communication Skills. Comprehensive knowledge of the health insurance industry, including, but not limited to: claim adjudication procedures; insurance law; benefit design; plan document provisions and compliance regulation. Adequate computer skills including an understanding of the capabilities of basic software (word processing, online presentations, databases, spreadsheets). -- Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, physical disability or any other classification protected under local, state or federal law. Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.