Department:OH1CH_70505_000 MCHP-Claims Operations & System Configuration
Expected Weekly Hours:40
Position Purpose:At Mount Carmel, we work to continuously inspire one another. Here, all are welcome. It is this culture of humility and compassion that sets Mount Carmel apart. We see the big picture and do the right thing. That means a dedication to the well-being our both our colleagues and the patients they serve.
MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries in Ohio. 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.
Job Description Details:
The Director, Claims Operations and System Configuration directs the activities of all reporting positons in the Claims Operations, Claims System Configuration and Special Investigation Unit departments, including the delegated (vendor) relationships for claims processing to ensure the prompt and accurate adjudication of claims; accurate claims system and benefits configuration; achieve cost objective and service level goals; collaborate with all other departments to ensure MediGold goals are achieved and compliance with Centers for Medicare and Medicaid Services (CMS) guidelines are met.
- Establish standards of performance, including training, policies and procedures, claims auditing, fraud, waste and abuse policies, and other performance measurement techniques.
- Oversee all activities related to claims processing, claims system configuration, and fraud, waste and abuse prevention efforts.
- 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.
- 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.
- Through auditing and internal reporting, proactively identify negative or positive trends and report to management with recommendations for change.
- Oversight of the administration, configuration and ongoing maintenance of the MediGold 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.
- All other duties as assigned.
- Education: Bachelor's degree required.
- Licensure / Certification: CPC or equivalent preferred.
- Experience: 8-10 years of Managed Care experience, preferably in Medicare Advantage; 5 plus years of previous management experience in an office environment analyzing and developing production systems and procedures.
- Experience with Medicare and corresponding regulatory requirements preferred.
- Experience with Medicare audit protocols and audit readiness procedures a plus.
- Comprehensive knowledge of the health insurance industry, including, but not limited to: claim adjudication procedures; fraud, waste, and abuse; claims system configuration and benefit design; insurance law; document provisions and compliance regulation preferred.
- Knowledge of value-based provider partnerships a plus.
- Experience with the annual Medicare bid cycle a plus.
- Ability to provide strong and resilient leadership in an evolving team environment within a growing organization.
- Effective communication skills, with excellent written and verbal presentation and interpersonal communication skills required.
- Comprehensive computer skills, including an understanding of the capabilities of basic software (word processing, online presentations, databases, spreadsheets, etc.).
Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us.
Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, sexual orientation or physical ability.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.