Claims Administration Director (Remote)

LOCATION: Remote - This is a home based, virtual position that operates Monday - Friday from 8:30am-5:00pm EST. Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL. Preference will be given to a North Carolina resident located in/near our catchment area. There may be a need/request for this employee to travel to Vaya's Asheville NC office on rare occasion.

GENERAL STATEMENT OF JOB

The Claims Administration Director is responsible for providing leadership and direction, policy and procedure guidance, monitoring, analysis, reconciliation, resource allocation, and coordination to the Claims Administration and Claims Encounter Management teams. This position is also responsible for overseeing the provider claims adjudication process in the Managed Care Information System (MCIS), encounter reporting to the Department, including Consumer Data Warehouse (CDW) reporting. The Claims Administration Director is responsible for working with the Claims Administration department to ensure claims adjudication quality control activities are monitored and adhered to as required by Vaya Heath (Vaya) policy. Additionally, this position will work closely with Vaya leadership across the organization, including Plan Configuration, Information Technology, Contracting, Network Provider Relations, Regulatory Affairs, and Clinical Support to meet Vaya's strategic plans and objectives. The duties listed within pertain to both the Medicaid Direct and Tailored Plan which requires oversight for behavioral and physical health claims management.

ESSENTIAL JOB FUNCTIONS

The Claims Administration Director responsibilities include (but are not limited to) the following:

• Management and Supervision
• Internal & External Collaboration and Oversight
• Administrative Duties
  1. Provides leadership and direction in order to achieve established business goals and objectives.
  2. Establish team goals, objectives, and operating procedures.
  3. Provides leadership for the Claims Administration team to ensure that all claims are processed for payment accurately and in a timely manner.
  4. Identifies and resolves operational issues using well defined/documented processes, expertise, and judgment.
  5. Ensures the Claims Administration team participates in system testing to ensure continuous operations.
  6. Monitors departmental processing activities to ensure that Vaya's service, quality, productivity, service level agreements, and goals are achieved.
  7. Serves as Vaya's expert in the areas of provider billing, provider reimbursement, encounter reconciliation, member and recipient eligibility, and enrollment.
  8. Collaborates with other Vaya business teams to develop, document, and standardize procedures and workflows to support operational improvement.
  9. Participate as a Subject Matter Expert (SME) on systems operations, recommend changes for system design, methods, procedures, and workflows which enhance claims operations.
  10. Reviews, examines, and provides leadership for the processing and handling of unusual or complex claims or eligibility issues.
  11. Monitors weekly/monthly reports on claims activities; provides management with updates and progress reports.
  12. Manages the Claims Administration team to ensure adherence to all departmental policies and procedures, HIPAA regulations, and other state and federal requirements.
  13. Participates in Cross-Functional Teams (CFTs) as assigned.
  14. Attends State meetings as needed to stay informed of changes in local, State, Federal, and Division requirements.
  15. Ensure adjudication rules align with contractual and other regulatory requirements.
  16. Performs other independent duties and projects as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

• Extensive knowledge of claims management, Medicaid, and State funding rules and regulations, third-party payer, and coordination of benefits.
• Knowledge of various health insurers and coordination of benefits preferred.
• Knowledge and understanding of basic medical terminology.
• Knowledge of a capitated managed care environment.
• Knowledge of Tailored or Specialty Plans.
• Ability to influence strategies and results across multiple functional areas accountable for delivering the customer experience.
• Strong focus on the people side of change, including changes in business processes, systems, and technology, job roles, and organization structures.
• Drive adoption to change, higher utilization of and proficiency with the changes that impacts the staff.
• Ability to work independently, and communicate with associates, providers, and public.
• Organization, time management, planning and project management skills, ability to manage multiple priorities to meet deadlines.
• Ability to think both tactically and strategically in addressing issue resolutions.
• Excellent problem-solving and analytical skills.
• Ability to create/analyze reports and utilize data to drive results.
• Team-oriented and able to interact effectively with other staff.
• Proficient in Microsoft products to include Excel and Outlook.

EDUCATION & EXPERIENCE REQUIREMENTS

Bachelor's degree in Business Administration, Accounting, Finance, Healthcare, Human Services or related field required. Master's degree preferred.

• 10 years of claims processing experience; supervisory role with increased responsibilities over time.

Preferred work experience:

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position must live in NC, SC, GA, TN, VA, MD, or FL. Preference will be given to a North Carolina resident located in/near our catchment area. There may be a need/request for this employee to travel to Vaya's Asheville NC office on rare occasion.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled.

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.