Director, Claims Modernization, Claims Solution Lead

The Director, Claims and Provider Payment Modernization will apply skills at the intersection of business and technology to plan, organize, and implement initiatives supporting our Claims and Provider Payment Modernization program. S/he is a thought leader and implementer of our approach to enabling Operations staff to transition from legacy systems and processes to future-state, streamlined models and procedures. This role is instrumental in ensuring overall adherence to regulatory expectations while improving the overall quality of work output. This role requires cross-functional work to ensure department and corporate strategies are executed and achieved enterprise-wide.

Duties & Responsibilities:

• Assists in the development of strategic plans to ensure modern and efficient claims processing across the entire lifecycle with a focus on a unified, streamlined experience for both providers and operations staff
• Works closely with technology and business leadership to support the evolution and operation of a variety of digital claims capabilities on our modernization roadmap
• Analyzes project needs and determines people, process, and technology resources needed to meet objectives and achieve desired outcomes
• Ensures the successful completion of current and long-range department goals and objectives and monitors results on an ongoing basis, adjusting plans and performance expectations to achieve targeted performance improvement results
• Acts as a liaison between business and technology teams, ensuring accurate translation of ideas and concepts between the parties to align strategy
• Takes initiative, thinks analytically, and works independent of supervision as appropriate or needed
• Builds, manages, develops, and continuously improves the claims experience to meet the diverse and dynamic needs of a growing, evolving organization
• Develops an effective team through hiring, training, coaching, and providing ongoing and constructive feedback
• Communicates results to executive leadership using standardized reports, dashboards, and frequent verbal updates through participation in management meetings and operational review processes
• Develops, formulates, recommends, and implements decisions regarding policy, standards methods, procedures, and functions
• Ensures all NY state and federal compliance, audit and regulatory requirements are met
• Performs other duties as necessary or assigned     

Minimum Qualifications:

• Bachelor’s degree from an accredited institution or equivalent work experience
• Prior experience instituting change initiatives within an operational unit
• Proven ability to develop strong interpersonal relationships with key stakeholders, with experience communicating and influencing at the senior leadership level.
• Successful track record developing creative, workable strategies and tactics to accomplish division, corporate and plan goals
• Work experience requiring written and verbal communication that is clear, concise, grammatically correct, and professional

 Preferred Qualifications:

• Master's degree or MBA from an accredited institution
• Prior experience with claims and provider payment operations in a healthcare payor setting
• Experience setting departmental strategy, communicating, and influencing impact and progress to senior leadership
• Experience with Medicare/Medicaid and Commercial Healthcare
• Strong leadership capability with experience leading change, establishing a business strategy, setting performance targets/benchmarks and using metrics, team engagement protocols and innovative problem-solving techniques to drive execution of cost, quality and productivity areas for a large operation
• Demonstrated understanding and practical experience using Agile methodologies. Exposure to Scaled Agile (SAFe) preferred

Compliance & Regulatory Responsibilities: Noted above

License/Certification: N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst.  Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $150,800 - $230,690

• All Other Locations (within approved locations): $124,400 - $190,315

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.