Claims Quality Audit Director jobs in Idaho

Organization is seeking a highly skilled and experienced Director, Claims to join our team in Meridian, Idaho. As the Director of Claims, you will have overall responsibility and accountability for all aspects of healthcare claims operations. You will play a critical role in assuring timely and accurate benefit determinations for claims, while maintaining high service levels for our valued members and providers. This is a unique opportunity to make a significant impact and drive positive change within our organization.Responsibilities:

• Apply your vast experience to integrate diverse components of cross-functional business decisions and consistently enhance claims processes and procedures.
• Develop strategies, implement, lead, and champion quality process excellence and compliance requirements.
• Establish and maintain a system that evaluates claims performance and the customer experience.
• Identify areas for improvement, create action plans, provide guidance to team members, and ensure goals are met.

Requirements:

• 10 years of claims operations experience within the health insurance industry, including management experience
• Bachelor's Degree in Business or Healthcare Administration preferred, or equivalent work experience
• MBA (preferred).
• CMS certification (preferred).
• Knowledge of FEP benefits and pricing
• Experience with claims processing systems, including Facets
• Experience leading teams that excel in collaboration and achieving results
• Experience in inventory management and reporting

Knowledge, Skills, and Abilities (KSAs) needed in this role:Knowledge of:

• Components and principles of management production control
• Accounting principles
• Data processing management information system that affect claims processing
• Business budgeting processes
• Forecasting and planning techniques
• Health insurance contract benefits and provisions
• Health insurance provider pricing and networking

Skills:

• Strong collaboration and discernment
• Strong people leadership experience
• Excellent verbal and written communication
• Excellent motivational and staff recognition
• Proven management and leadership skills in a team-based environment
• Creative and analytical thinking
• Analytical and decision-making
• Proficient in Microsoft Office - Word, Excel, Outlook, and PowerPoint

Ability to:

• Collaborate with others to obtain effective working relationships and outcomes
• Be flexible and creatively respond to operating and system challenges
• Work with employees at all corporate levels
• Communicate effectively with members, providers, and other Blue Cross and Blue Shield Plans
• Manage multiple priorities and daily diverse activities
• Analyze and recommend process improvements for business operations
• Participate in and/or deliver presentations or discussions to a wide variety of internal/external audiences, such as sales presentations to important accounts

Your Day-to-Day:

• Assure cost-effective high service levels to members and providers through fair, accurate, consistent, and timely claims processing
• Assure that national and corporate standards are met for timeliness and accuracy in claims
• Represent Claims operational perspective in the development of corporate business rules
• Assure effective communication with department, division, and corporate levels of management
• Assure that department management information systems, core claims and benefits processing systems, and reporting capabilities are accurate and up to date
• Assure effective development and implementation of corporate initiatives and projects
• Establish department objectives that support company goals and produce regular status reports
• Prepare an operating budget that reflects the forecasted needs of the department and control expenditures
• Ensure effective workflows, improve system efficiencies, and monitor quality performance measures
• Initiate personnel actions such as hiring, disciplinary actions, and salary recommendations
• Promote teamwork, discussion, and cooperation among staff and other departments
• Develop and maintain departmental policies and procedures
• Direct the design, planning, and implementation of training programs aligned with operational objectives and strategies
• Collaborate with functional management to assess ongoing and future training and development needs
• Approve new training techniques and suggest enhancements to existing training programs
• Oversee and establish relationships with vendors to provide additional outside training programs
• Perform other duties and responsibilities as assigned

Job Type: Full-time

Pay: $145,000.00 - $155,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person

Education:

• Bachelor's (Required)

Experience:

• chief level: 5 years (Required)
• medical insurance claims: 10 years (Required)

Ability to Relocate:

• Meridian, ID: Relocate with an employer provided relocation package (Required)

Work Location: In person