The Role
The Director of Claims Operations will lead strategic planning to streamline operations, ensure accuracy in processing claims, and improve quality programs while coordinating with IT and service providers.
Summary Generated by Built In
Job Summary & Responsibilities
- Design and lead execution of strategic plans to streamline operations, reduce claim turnaround time, meet accuracy requirements and improve first-pass adjudication rates.
- Ensure all claims are processed in accordance with member benefits, provider contracts, regulatory requirements, and internal policies.
- Drive operational quality programs, ensure we are adhering to industry standards and best practices, and support internal and external audits.
- Partner with IT department and external service providers to enhance claims platforms and integrate automation, AI, and data analytics tools where applicable.
- Ensure cost containment through fraud prevention, coordination of benefits (COB), subrogation, and provider contract enforcement.
- Encourage a culture of continuous improvement, from the proper documentation of current state processes to proposing new solutions consistent with the future state.
- Work with production leadership and business areas to develop relevant, timely, and effective training related to organizational changes and quality issues.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
- Support relationship(s) with service providers as applicable.
#LI-Hybrid
Preferred Qualifications- Bachelor's degree and seven years of related work experience; or equivalent combination of education and related work experience.
- Five years of management/supervisory experience
- Expert experience developing and presenting actionable solutions to complex problems with C-Suite level.
- Effective written and verbal communication skill, including the ability to communicate and present complex issues in a concise and easy to understand manner.
- In-depth knowledge of managed care, PPO, HMO, Medicaid, Medicare Advantage, and commercial group health plans
- Strong working knowledge of claims adjudication systems (e.g., Facets, QNXT, Epic Tapestry, HealthEdge).
- Expert knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
- Intermediate knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.
Top Skills
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The Company
What We Do
The Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, is a reliable name in Hawaii health care. Established in 1938, we are the largest and most experienced provider of health care coverage in the state. Over half of Hawaii’s population have chosen HMSA for their health care coverage.
We are dedicated to providing quality, affordable health plans; employee benefit services; and worksite wellness programs. HMSA also offers a variety of programs, services and support to help improve the health and well-being of our members and community.
