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Head of Claims Operations and System Oversight

2 months ago

Austin Texas, United States Central Health Full time

Position Summary:


The Head of Claims Operations and System Oversight is tasked with the leadership and organization of the Claims Team and the management of Claims Systems for a Health Maintenance Organization (HMO) and additional Health Plans operating in Texas.

This position guarantees the prompt and precise processing of Health Plan Claims, while also ensuring that the VBA Claims System is appropriately configured by each assigned departmental team.


Key Responsibilities:


1. Recruits, supervises, and directs the following Health Plan Claims teams: System Configuration, Claims Management & Adjudication, Audit & Appeals, and Coordination.

2. Formulates strategies and executes quality claims processes in accordance with compliance standards.

3. Establishes claims adjudication objectives and implements a framework to accomplish them.

4. Collaborates with departmental staff across the Health Plan on claims processes and system specifications.

5. Manages and coordinates with Claims System vendors to ensure optimal operational functionality.

6. Prepares and delivers regular reports to the Executive team.

7. Provides support to the Compliance team during any internal or external audits as necessary.

8. Develops and maintains training programs for Claims Process and System Management.

9. Performs additional duties as assigned.

Qualifications:

EDUCATION:
A High School Diploma is required.

A Bachelor's Degree in Healthcare Administration, Business Management, or a related field is preferred.

EXPERIENCE:
A minimum of 7 years in Health Plan Claims Management or Supervision, ideally within an HMO or managed care setting is required.