Now is the time to join us! 

Who are you?

The Director of Claims Operations identify opportunities for improvement, create operational and change management plans to be rolled out to out claim processing teams. In addition, they will manage and direct several of the high-risk operational claims teams. This is an integral leadership role that has an enormous impact on various team members and our rapidly growing organization.   

The Claims Operations Director will play a critical role in enhancing the efficiency and effectiveness of claims processes. By employing a systematic approach and developing as well as deploying best practices, this leader will enable a culture of continuous improvement of operations.

In this role you will wear many hats, but your knowledge will be essential in the following:  

• Manage and develop a team of high risk claims examiners, special situations as centers of excellence and guide supervisory staff through education, experience and motivation which contributes towards success.
• Have a detailed and organized work plan and to assign duties, responsibilities, and scope of authority.
• Maintains knowledge and implements procedures to comply with government regulations as it pertains specifically to Medicare, HIPAA, FMLA and any other regulation impacting claims.
• Reviews, refreshes, and standardizes procedures to improve efficiency and enable excellence.
• Coach and guide team members for client, process, and best practices through training, tools, and team governance.
• Maintains knowledge of government regulations as it pertains to claims payments and recognized claims standards.
• Conduct Reviews and ensure documentation for compliance to production standards in terms of quality, quantity, and documentation.
• Overall Inter personnel guidance and coordination.
• Talent Assessment, Recognition and Review as well as Succession Planning
• Identify and develop an organization of high-risk special work packages for maximum efficiency as well as effectiveness.
• Coordinates the handling and release of pended claims, claims that exceed monetary authority, claims with special handling instructions and claims which exceed specific reinsurance levels.
• Troubleshoots claims mistaken payment and problem inquiries.
• Review aggregate reinsurance audits and follows the High Dollar Matrix for RACI ownership.
• Assists and coordinates with various resources for fraud claims/providers.
• Acts as the liaison for the organizations legal department.
• Coordinates the handling of Medicare Supplement Recovery Payments with CMS and the Department of Treasury.
• Coordinates and assists with documentation for responses to lawsuits as well as Department of Labor request.
• Responds to correspondence regarding lawsuits, insurance complaints, audits and inquiries requiring management attention.
• Investigates and responds to letters of inquiry from the plans, providers, networks, and government agencies.
• Drive a minimal defect backlog through partnership with technology and vendor partners.
• Involvement in Request for Proposal (RFP’s) for new business as needed both for consultative and logistical support.
• Balances the need for growth, retention, and profit to meet corporate objectives.
• Oversees new business implementations and other mission critical rollouts.
• Confers with project personnel to provide technical advice and to resolve problems.
• Coordinates the implementation and maintenance of electronic data interchange (EDI)

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

What you bring to the Personify Health team:

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

• Bachelor’s degree in business administration, Health Administration, or related field
• 10+ years of TPA experience specifically overseeing the Claims function
• Strong leadership skills and the ability to mentor and coach team members

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

• Highly organized and process oriented
• The ability to communicate with a variety of stakeholders and business leaders
• Ability to lead and inspire large, diverse teams.
• Strong knowledge of claims processing systems and regulatory requirements.

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you!

Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $145,000 to $158,00. Note that compensation may vary based on location, skills, and experience. This position is eligible for 10% target bonus/variable compensation as well as health, dental, vision, mental health and other benefits.

We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.

#WeAreHiring #PersonifyHealth

Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to talent@personifyhealth.com. All of our legitimate openings can be found on the Personify Health Career Site.

Application Deadline: Open until position is filled.