The Director of Operations provides leadership, direction, and subject matter expertise for the Claims and Call Center operations including related technical expertise, provider appeals, quality assurance and training. The successful candidate will be responsible for delivering an excellent experience to all of the company's customers that have non-sales questions or problems. Actively leads cross-departmental initiatives and fulfillment of the company’s strategic objectives.
Essential Job and Duties:
- Manages day to day operations of the claims and call center departments.
- Directs staff through coaching, professional development, work allocation, problem resolution, performance evaluation, and related supervisory activities.
- Directs employees engaged in receiving calls and inquiries, investigating, evaluating, and settling complaints and claims of customers.
- Defining appropriate metrics that measure the quality of the customer service being delivered and the quality of the claims processing as well as the cost of delivery.
- Develops and maintains a systematic training program for staff members.
- Designs and maintains a structured performance program for staff members -- sets productivity and quality standards based on benchmarks, historical performance, and trends; tracks performances against standards and holds individuals accountable; motivates employees to exceed standards through an incentive program.
- Ensures departmental compliance with contractual, regulatory, and company requirements, guidelines, and goals including turnaround times, average speed of answer and reporting.
- Tracks trends, makes decisions based on organized information, and supports decisions with articulate written and verbal communications. Creates annual budget and is responsible for the budget oversight of department. Provides business justification for capital and resource needs.
- Responsible for cross organizational project leadership and provides representation for new products and initiatives.
- Documents and implements new policy; trains others in the critical success factors of the policy.
- Interacts with providers, employers and members concerning escalated matters of significance and seeks win-win solutions.
- Collaborates with peers and other departments to optimize service levels, payment accuracy, turnaround times, and other operational efficiencies. Lends subject-matter expertise to their initiatives.
- Directs functional leaders in Claims and Call Center, including staff of 30-35.
- Bachelor’s degree required
- Must have at least 5 years of experience at the Manager level or higher in administration of Claims
- Minimum four (4) years comprehensive medical claims processing experience
- Some travel required both intra and interstate
- Previous experience at the Manager or Director level in administration of Claims for a Medicaid managed care organization, preferred
- Hands-on experience using LuminX desirable
- Customer service management experience preferred
Competencies, Skills, and Attributes:
- Able to build strong teams with complementary skills, and to lead, motivate, and inspire teams.
- Able to develop creative strategies and to tap the potential of individuals and groups.
- Able to continually assess needs and implement measures that will ensure customer expectations are met or exceeded.
- Able to turn problems into opportunities for change.
- In-depth knowledge of claims processing in a managed care environment. Knowledge of peripherals for which claims is dependent such as member eligibility, prior authorizations, and provider records.
- Strong writing skills that exhibit concise, descriptive, and professional prose. Confident presentation skills.
- Strong presentation skills.
- Able to diplomatically and professionally interact with providers and employers concerning routine and escalated matters. Ability to communicate effectively at all levels of the organization.
- Knowledge of types of health care providers and their operations especially related to billing and accounts receivable practices.