VetJobs - The Leading Military Job Board

We are recruiting for a Director, Claims - Denver Health Medical Plan to join our team!

We are here for life's journey. Where is your life journey taking you?

Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all:

Humanity in action, Triumph in hardship, Transformation in health.

DepartmentManaged Care Administration

*Remote Opportunity. Must Be a Colorado Resident*

Job Summary

As the Director of Claims and Enrollment, you will lead the strategic vision and execution of operations critical to our organization's claims and enrollment functions. Your core responsibilities involve overseeing comprehensive audits, ensuring contractual compliance, and implementing continuous monitoring practices. By leveraging your expertise, you will drive effective stakeholder communication, streamline issue resolution, and introduce innovative solutions to enhance operational efficiency. This position provides a unique opportunity to shape and enhance the organization's claims and enrollment functions, driving continuous improvement and contributing to overall business success through strategic leadership and effective operational oversight.

Essential Functions:

Claims, Enrollment and Configuration Operations Management * Oversee and manage the daily operations of the function. Adheres to the rules, regulations, and contractual requirements of CMS, CO Medicaid, CO Division of Insurance, contracted and non-contracted providers.

• Manage vendor oversight program of outsourced activities to ensure the contractual performance meet expected outcomes including appropriate turnaround time, accuracy, quality assurance program(s), and issue resolution. To include Audit Planning and Execution:
• Lead the planning and execution of audits to assess vendor performance, compliance, and adherence to contractual Service Levels and Key Performance Indicators.
• Conduct thorough risk assessments to identify potential areas for improvement and develop audit programs accordingly. Continuous Monitoring:
• Establish and maintain a robust continuous monitoring framework to proactively identify and address emerging risks and issues related to vendor relationships.
• Implement key performance indicators (KPIs) and metrics to measure vendor performance and compliance on an ongoing basis.
• Leverage technology solutions for data analytics, automation, and reporting to enhance the efficiency and effectiveness of vendor auditing processes. Issue Resolution and Remediation:
• Lead the resolution of issues identified through audits or other operational escalations, working collaboratively with cross-functional teams to implement corrective and preventive actions.
• Monitor and track the progress of remediation efforts to ensure timely resolution of identified issues. Stakeholder Communication:
• Regularly communicate audit findings, performance metrics, and risk assessments to senior leadership and key stakeholders.
• Facilitate constructive dialogue with vendors to address concerns, provide feedback, and drive continuous improvement. (60%) Cross Departmental Collaboration
• Implement operational changes necessary to maintain compliance with regulatory guidance affecting internal teams and external vendors; guarantee the organization's adherence to all applicable laws and regulations.
• Oversee updates and changes to system configuration and team operating procedures to ensure the processing and payment of claims align with Utilization Management policies; collaborate with leadership to promptly address arising issues.
• Collaborate with the Contracting team to verify that claims are processed in accordance with the contract and partner with Provider Relations to resolve any inconsistencies.
• Develop, modify, review, and implement policies and procedures for pricing changes, contractual modifications, and adjustments
• Monitor and detect potential fraud and abuse, ensuring continuous regulatory compliance across all operations; share findings with Payment Integrity and Compliance teams. (25%) Staff Management & Training
• Work with Direct Reports and teams to manage daily operations- Claims Manager, Enrollment manager and Configuration Lead
• Manage the daily operations of the Claims Operations staff, including hiring, training, supervising, evaluating, and developing the Claims Manager, two Business Care Analysts, and two Claims Processors.
• Develop, review, and present reports on productivity and accuracy.
• Develop comprehensive training programs and ensure acquisition of knowledge related to all claims policies and procedures. Ensure vendor adherence to same policies and... For full info follow application link.

"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national