Director of Claims

Our client, a fast-growing company who specializes in self-funded employe benefits firm is seeking a Director of Claims & Cost Containment. This position will work a hybrid schedule and will act as a strategic leader who is responsible for overseeing and optimizing our insurance claims management processes/cost containment strategies. This individual will be a team of one to begin with and report into the VP of Stop Loss. You will help develop innovative solutions to enhance operational efficiencies and ensure compliance with regulatory standards. The ideal candidate will possess extensive experience in insurance claims management, a strong grasp of cost containment techniques, and a proven track record of leadership in a dynamic organizational setting. Moreover, the company is currently doing the post care prepayment piece of cost containment (i.e. reducing bills that have already happened, assess billing errors, assess charges, etc). We are looking for someone who can establish process to help monitor incoming claims, negotiate the claims, over the vendor partners, and perform bill reduction strategies.

• Claims Analysis & Review

Ensure financial accuracy of claims processing of all TPA’s

Research & apply appropriate claims processing rules & regulatory policies

Create reimbursement policies when needed

Review of benefit plans

Responsible for reporting month & quarterly findings

Complete specialized focused audits

Monitor precert and CM activity, performing precert audits pre/post appointment

Perform Quarterly Claim Audits of specific category as well as TPA claim processing audits.

• Contract Negotiations

Interpret Provider Contracts for proper payments to ensure claims systems are paying appropriately

Negotiate with providers for when applicable

Analyze financial impact of contracts & terms

Build relationships & be the point of contact