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  • Director, Claims Operations (Managed Care Administration)

    Denver Health
    Job Description
    Job Summary:
    The Director of Claims Operations develops, directs, implements, and oversees the management and payment of claims for all lines of business at Denver Health Medical Plan. Develops and implements all related processes and manages the external benefit configuration vendor. Responsible for managing the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with contracted fee schedules and covered benefits as specified. Hires, supervises, and develops all staff. Actively participates as a member of the Plan’s Operations Management Team.


    Minimum Qualifications:
    Education:
    Bachelor’s degree is required

    Experience: Typically, five to seven years of claims management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines. Strong experience in managing claims system development, configuration, and maintenance. Experienced in managing claims processing for Medicare, Medicaid, CHP+, Large Group Commercial, and Healthcare Exchange. Demonstrated track record in creating approaches, policies, and procedures to ensure effectiveness of the claims payment and adjudication process at a health plan.

    Knowledge, Skills & Abilities: Solid system development and evaluation abilities, effective leadership and management, and outstanding written and oral communication skills are required. Experience and proficiency with Trizetto QNXT is highly desired. Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services (“CMS”) and the Colorado Department of Health Care, Policy & Financing (“HCPF”) is required. Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA. Knowledge of bundled payments, risk-sharing, and provider capitation is essential. Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems. Able to perform effectively in a leadership role and evaluate processes for efficiency. Experienced in supervising staff and ensuring key tasks and goals are met on a timely basis.

    Certificate/License/Registration: All Certifications and Licenses required for this job must be kept current as a condition of continued employment.