Director, Claims Life Cycle Management & Implementation

Job Summary:

The Director, Claims Life Cycle Management and Implementation is entrusted with overseeing and directing the strategic enhancement of claim outcomes across existing and emerging lines of business within the Claims organization. This pivotal role involves orchestrating collaborative efforts with cross-functional teams to devise and implement project strategies, mitigate risks, monitor progress, lead process optimization endeavors, and create transformative change. Expert-level comprehension of the end-to-end claims process, adept project management skills, and exceptional communication and interpersonal abilities are imperative for success.

Essential Functions:

• Define and influence the functional requirements of Facets provider, configuration, and claims end-to-end adjudication processes, encompassing claim intake, pre-adjudication, adjudication, post-adjudication, and payment procedures
• Develop and ensure execution of implementation plans, including timelines, budgets, and resource allocation, while ensuring risk management and adherence to project milestone
• Be the conduit between technical and business perspectives, guaranteeing that technical solutions align seamlessly with business imperatives
• Collaborate with business, architecture, and infrastructure units to uphold exceptional service levels and bolster stakeholder satisfaction
• Lead the seamless implementation of new lines of business within the Claims organization, proactively identifying future system enhancements and opportunities
• Perform detailed analysis of data, workflows, policies, procedures, organization of staff, skills and offer potential solutions to execute growth initiatives
• Oversee the analysis of business processes and development of functional requirements and appropriately document and communicate captured information for validation and re-usability
• Maintain diligent oversight of project progress, providing regular updates to stakeholders and driving consensus to ensure project integrity and efficacy
• Manage risk and ensure implementation activities are completed on time and within budget
• Conduct intricate data analysis, workflow evaluations, and policy assessments to propose and execute initiatives aimed at refining operational efficiency and resolving complex technology and process-based challenges
• Organize work teams, drive consensus, and ensure end-to-end policy and process integrity to accomplish project work, including stakeholder participation; establishment of a project plan; meeting facilitation; consensus building; recommendation and decision documentation, and implementation oversight
• Stay abreast of industry best practices and regulatory mandates, integrating them into claims processes to ensure adherence and compliance
• Ensure compliance with regulatory and contract obligations in new business implementations
• Foster a culture of continuous improvement, contributing to the development and enhancement of claims processes, while nurturing a high-performance team environment
• Perform any other job duties as requested

Education and Experience:

• Bachelor's degree in business administration, healthcare administration, or a related field, or equivalent years of relevant work experience is required
• Minimum of five (5) years of progressive experience in healthcare claims management or a related field is required
• Minimum of three (3) years of project management experience is required
• Facets experience is required
• Management/leadership experience is required

Competencies, Knowledge and Skills:

• Advanced skills in Microsoft Office suite
• Proven track record of successfully implementing new managed care products
• Exceptional project management acumen, and a proven track record of successfully implementing new managed care products
• Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets
• Demonstrated strategic acumen and ability to drive operational excellence
• Outstanding communication skills, both written and verbal
• Effective listening and critical thinking skills
• Demonstrated strong problem-solving and decision making skills
• Ability to create and maintain effective working relationships

Licensure and Certification:

• Project Management Professional (PMP) certification preferred

Working Conditions:

• Standard office environment with potential for extended periods of sitting or standing
• Occasional travel may be required based on business needs

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.