Claims Director (Remote Option)

Competitive Compensation & Benefits Package!  

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Remote Option; Must live in NC or within 40 miles of NC border.

Projected Hiring Range:  Depending on Experience

Closing Date:   Open Until Filled

Primary Purpose of Position: This position performs difficult and technical work related to claims adjudication and is responsible for operationalizing the work of the Claims department. Provides oversight and management of the Claims Manager, Medical Coder, and Encounters Supervisor. Work is performed under supervision of the Senior Claims Director. 

Role and Responsibilities:  

Responsibilities may include but are not limited to: 

• Serves as the MCO expert in the areas of provider billing and provider reimbursement, with specialized expertise in various billing methodologies, including ED, per diem, DRG, etc.
• Provides leadership in billing and claims planning and operational governance, in order to achieve established
• Business goals and objectives
• Provides leadership for the claim’s functions of the MCO to ensure that all claims process for payment    
• Accurately and in a timely manner, ensures suspended, voided and adjusted claims are resolved
• Monitors claims adjudication workflow, and uses audit and reconciliation and other quality control measures to assure correct claims adjudication and payment is occurring and prompt pay guidelines are being met
• Performs review of claims adjudication and conducts post claims adjudication and billing analysis utilizing various reporting tools
• Provides leadership in the monitoring of claims activity for the purpose of identifying providers experiencing a high volume of claims issues
• Provides technical assistance and technical training to claims staff
• Monitor daily, weekly and monthly reporting of the progress of software system
• Reporting will include but not limited to prompt payment compliance, weekly batch processing, remittance results and State reporting
• This position directly supervises Claims Manager, Medical Coder, and Encounters Supervisor. 
• Supervision requires the ability to plan, delegate and oversee workflow as well as schedule, communicate with and develop staff
• Monitor and evaluate job performance on an ongoing basis and when appropriate recommend increases, disciplinary action, or termination
• Update job descriptions as needed, based on changes in responsibilities; educate on job duties and responsibilities  
• Coordinate and complete performance evaluations
• Schedule work time and leave to ensure tasks are accomplished in a timely manner and responsibilities are met  
• Establish staffing patterns for work unit and making recommendations regarding additional staff needs
• Serves as coach/mentor for department
• Communicate and implement any organizational changes, policies, procedures or information updates to staff  
• Participate in employment personnel training and providing education and support resources to staff, i.e., training and development

Knowledge, Skills and Abilities:  

• Considerable knowledge of medical claims processing and provider reimbursement
• Considerable knowledge of automated claims processing systems
• Considerable knowledge of the principles and practices of public and business administration and office procedures, practices, and equipment
• Considerable knowledge of accounting practices and procedures
• General knowledge of personnel policies and procedures
• Excellent computer skills including proficiency in Microsoft office products
• Analytical problem solving, verbal and quantitative skills
• Ability to work with Technical IT staff and contractors to trouble shoot system issues and assure system integrity
• Ability to initiate and apply administrative programs and procedures to evaluate their effectiveness
• Ability to exercise judgment and discretion in establishing, applying, and interpreting policies and procedures
• Ability to plan, assign, and supervise the work of subordinate employees
• Ability to establish and maintain effective working relationships with agency personnel, officials, and the general public

Education and Experience Required: Bachelor’s Degree with a major in Accounting, Business, Public or Hospital Administration, five (5) years experience in medical claims processing including four (4) years experience in business or governmental programs; or an equivalent combination of education and experience that includes five (5) years of medical claims processing. Must have three (3) years of administrative supervisory experience.  

Education and Experience Preferred: MBA/MHA preferred. Experience in the public mental health field or a managed care organization is highly desired due to the complexity of the work of the organization.  

Licensure/Certification Requirements: CSS, CCSP or CCSH is strongly preferred.