Director Claims

1 week ago

Meridian, Idaho, United States Blue Cross Blue Shield companies Full time

Blue Cross of Idaho (BCI) is looking for a Director, Claims to have overall responsibility and accountability for all aspects of healthcare claims operations to assure timely and accurate benefit determinations for claims, while maintaining high service levels for members and providers. This role will leverage experience and integrate various components of cross-functional business decisions to continuously improve claims processes and procedures, as well as develop strategies, implement, lead, and champion quality process excellence, and compliance requirements. The Director will establish and maintain a system that evaluates claims performance and the customer experience. The individual in this role is responsible for identifying areas of opportunity, developing solution plans, coaching team members and ensuring key metrics are achieved.

This is an onsite leadership position located in Meridian, Idaho and reports to the VP, Member Services. #LI-Onsite

To be considered for this opportunity you have

Experience: Ten (10) years experience in health insurance industry to include management experience

Education: Bachelor's Degree in Business, or Healthcare Administration preferred; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)

We'd also love it if you had:

  • Master of Business Administration (MBA) or related field
  • CMS Compliance experience
  • Knowledge of FEP benefits and pricing
  • Experience with Facets system
  • Experience leading hybrid, high performing teams
  • Experience in inventory management and reporting

Knowledge, Skills and Abilities (KSAs) needed in this role:

Knowledge of
  • Components and principles of management production control
  • Accounting principles
  • Data processing management information system that affect claims processing
  • Business budgeting processes
  • Forecasting and planning techniques
  • Health insurance contract benefits and provisions
  • Health insurance provider pricing and networking
Skills
  • Strong collaboration and discernment
  • Strong people leadership experience
  • Excellent verbal and written communication
  • Excellent motivational and staff recognition
  • Proven management and leadership skills in a team-based environment
  • Creative and analytical thinking
  • Analytical and decision-making
  • Microsoft Office - Word, Excel, Outlook and PowerPoint
Ability to
  • Collaborate with others to obtain effective working relationships and outcomes
  • Be flexible and creatively respond to operating and system challenges
  • Work with employees at all corporate levels
  • Communicate with subscribers, providers, and other Blue Cross and Blue Shield Plans
  • Manage multiple priorities and daily diverse activities
  • Analyze and recommend process improvements for business operations
  • Participate in and/or deliver presentations or discussions to a wide variety of internal/external audiences, such as sales presentations to important accounts

Here's what your day may look like:

  • Assure cost effective high service levels to members and providers through fair, accurate, consistent and timely claims processing.
  • Assure that national and corporate standards are met for timeliness and accuracy in claims. Participate in the establishment and negotiation of performance guarantee standards for large group accounts. Ensure these standards are met for areas under the Director's purview.
  • Represent Claims operational perspective in a productive manner and participate in the debate/analysis of the pros and cons of the issues when corporate business rules are developed.
  • Assure effective communication with department, division, and corporate levels of management by reporting significant issues and events on a timely basis. Promptly report significant issues and events to the Vice President.
  • Assure that department management information systems, core claims and benefits processing systems, and reporting capabilities are in place and accurately reflect the work environment and outcomes.
  • Assure effective development and implementation of corporate initiative and projects by participating as a member of the related project steering committees when assigned.
  • Establish department objectives that support company goals and produce regular status reports.
  • Prepare an operating budget that reflects the forecasted needs of the department and control expenditures to assure adherence to approved budgets.
  • Ensure effective workflows, improve system efficiencies, monitor quality performance measures and confirm appropriate completion of work assignments. Make recommendations for change as appropriate.
  • Initiate personnel actions such as hiring, disciplinary, termination and/or salary recommendations.
  • Participate in training, coaching and motivation of employees including career path development. Assess individual employee performance and conduct timely performance appraisals.
  • Promote teamwork, discussion, and cooperation among staff and other departments. Ensure timely communication and sharing of information with team members.
  • Work with staff to resolve work-related issues and concerns. Promote a respectful and diverse workplace.
  • Develop and maintain departmental policies and procedures.
  • Direct the design, planning, and implementation of training aligned with the objectives and strategies of the operational areas.
  • Collaborate functional management to assess ongoing and future training and development needs, as well as, the effectiveness of current training programs.
  • Approve new training techniques and suggest enhancements to existing training programs.
  • Oversee and establish relationships with vendors to provide additional outside training programs.
  • Perform other duties and responsibilities as assigned.

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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