Martin’s Point Health Care

Martin’s Point Health Care

Senior Director, Claims & Payment Integrity - Remote

Portland, ME · Director

Sponsorship not specifiedDetected 30 days ago
ComplianceProduct ManagementProduct StrategyFinancial ModelingInventory ManagementResearchLeadershipCommunicationProblem SolvingCritical ThinkingClaims Management

About the role

  • The Senior Director, Claims & Payment Integrity, is responsible for oversight of health plan claims administration and payment integrity functions.
  • Oversee strong inventory management processes and enhance auto adjudication
  • Ensures operational readiness, testing, training, reporting, and communications are in place for claims processing updates

Responsibilities

  • The position will develop, maintain, and optimize process flows to maintain claims payment accuracy.
  • Oversees the research, development, implementation, ongoing operational maintenance and administration of provider payment methodologies and fee schedules for all provider types in support of provider contractual arrangements
  • Demonstrates working knowledge in the design and roll out of alternative payment methods that are focused on an incentive-based pay for value approach.
  • This will require partnering cross organizationally to support the development of these new programs, and direct the operational activities necessary to stand them up
  • Delivers strong vendor oversight to optimize system processing to improve efficiency and accuracy; pursue new vendor opportunities including Request for Information (RFI)/Request for Proposal (RFP) as deemed appropriate
  • Collaborates with business and IT teams to ensure system and operational readiness for system fixes, configuration, and project rollouts impacting claims processing
  • Oversees, develops, and maintains documentation for claims and configuration processes and procedures with appropriate controls, reporting and quality assurance

Requirements

  • Experience with test plan development, strategy, and execution
  • Detailed knowledge of applicable regulatory and accrediting body standards (National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services (CMS))

Nice to have

  • Bachelor's degree required
  • Master's in business administration or comparable advanced degree strongly preferred

Skills

  • Demonstrates an understanding of and alignment with Martin's Point Values.
  • Excellent workflow and inventory management skills.
  • Excellent problem solving, quantitative and analytical skills with the ability to assess performance against metrics.
  • In-depth technical knowledge and ability to learn new technologies; knowledge of the Software Development Life Cycle (SDLC).
  • Knowledge of industry standards for claims and enrollment configuration, reporting and analysis.
  • Knowledge of benefit coverage and servicing members, providers, and the DoD, CMS/ Medicare Advantage, and ME state insurance coverage.
  • Knowledge of managed care computer systems, features, and reporting.

Benefits

  • Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond.
  • As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community.
  • Drives quality, timely claims processing to allow the health plan to achieve regulatory compliance, robust financial management and product strategy outcomes

Company info

  • Develops and maintains positive, effective working relationships with colleagues, vendors, and other internal and external customers.

Visa & Work Authorization

  • This position is not eligible for immigration sponsorship.
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This listing is sourced directly from Martin’s Point Health Care's careers page and normalized into a canonical job model.