Director Claims Cost Containment: 005850

Summary:

The Director of Claims Cost Containment is responsible for the development and execution of cost-containment strategy. The position provides senior management with evaluations and recommendations on the reliability and integrity of financial and operational information.

Essential Responsibilities/Accountabilities:

• Develops and implements department goals and corresponding action plans, and monitors performance against these.
• Directs quality focused analytical support with the aim of resolving and preventing systemic claims cost issues.
• Directs programs to ensure operational claims transactions are consistent with contractual terms in provider and employer contracts, as well as medical policies.
• Creates and implement strategies for all aspects of the Claims Cost Containment Department with overarching goal and objective to find errors, respond to trends, determine root causes, recommend fixes, increase transactional accuracy, and recover claim over-payments with consistency in approach.
• Develops, articulates, and implements the corporate claims cost containment/recovery strategy based on competitive intelligence, knowledge of industry tools, efficiency, common methodology, and common objectives.
• Collaborates with other divisions to identify and/or report areas of improvement, remediate system issues, and support corporate goals and initiatives.
• Orchestrates and recommends action plans, processes and policies for the recovery of funds based on a multi-disciplinary approach that takes into account the full appreciation of all events, circumstances, and decision making that initially lead to the overpayment.
• Focuses on closed-loop recovery trends and methods to remediate thereby shifting trends to cost containment demonstrating year over year improvements.
• Oversees Health Plan, recovery efforts for all lines of business. Assures that employer group, DOH, NYSID and the Attorney General requirements are met as related to contractual management practices.
• Conducts cost benefit analyses regarding new review processes.
• Provides direction and oversight for vendors providing claims recovery services and manages the related fees.
• Provides direction and oversight for all recovery services provided on a contractual basis to external entities and ensuring contractual obligations are met.
• Manages department budget and collaborates with Finance on budget impacts.
• Conducts trend analysis, forecasting, and identification of financial and transactional impacts of contract provisions, settlements and process changes across all regions and lines of business before they are finalized.
• Develops and manages department executive summaries relative to performance measurements, i.e. Savings reports, closed loop reporting, ROI analyses, inventory management, and productivity reports.
• Acts as an internal consultant on special operational and corporate projects related to cost containment/recoveries.
• Serves as a standing, active member on Company Committees as assigned.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Models the Lifetime Way behaviors and values on a consistent basis and promotes these behaviors to the division. This includes focusing on leadership development to ensure we are hiring, developing and retaining leaders to deliver operational excellence.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Minimum Qualifications

• Bachelor's degree in Accounting, Finance, Business Administration or related field with a minimum of seven (7) years of related experience of which three (3) years spent in a defined leadership role. In lieu of degree, a minimum of thirteen (13) years of progressive leadership/management experience in related field.
• Experience with health care services and insurance claims supported by a thorough knowledge of managed care principles, computer applications and corporate benefits and riders.
• Must possess strong leadership skills as well as the ability to effectively direct people and multiple projects.
• Must possess strong and effective analytical and problem-solving skills along with the capacity to identify and understand business objectives and associated risks.
• Must maintain a high level of objectivity and independence.
• Experience managing large scale change initiatives.
• Ability to develop and maintain constructive relationships with internal customers, the provider community, program administration and other Health Plans.
• Must possess excellent verbal and written communication, human relations and negotiation skills as well as the ability to interact effectively with individuals at all levels of management throughout the organization. Fully proficient to present findings and recommendations to senior management.

Physical Requirements:

• Ability to complete work in a traditional office environment under fluorescent lighting.
• Ability to orally communicate.
• Must be able to function while sitting at a desk viewing a computer and using a keyboard and mouse for 3 or more hours at a time.
• Must be able to travel across the enterprise.
• Ability to work in a home office for continuous periods of time for business continuity.



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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer