Director of Claims Operations

People. Passion. Purpose.

At P3 Health Partners, our promise is to guideour communities to better health, unburden clinicians, align incentives andengage patients.

We are a physician-led organization relentlessin our mission to overcome all obstacles by positively disrupting the businessof health care, transforming it from sickness care into wellness guidance.

We are looking for a Director of ClaimsOperations. If you are passionate about your work; eager to have fun;and motivated to be part of a fast-growing organization in Las Vegas, Nevada,then you should consider joining our team.

JOB SUMMARY:

Provides day to day oversight of the Claims OperationsDepartment (Claims, Configuration, Audit & Appeals and Mail Room). Theposition works with the SVP, Operations to identify and implement short andlong-range goals, coordination of operations staff, enhancements of businessdevelopment efforts and a continued focus on optimization in areas of claims, compliance,quality and reporting. The Operations Director is responsible for ensuringcompliance with company policies, procedures, and State and Federal regulatoryrequirements for operations under his/her management.

Reports to the SVP, Operations. Serves as amember of the leadership team in developing goals and objectives andimplementing Population Health Management initiatives that impact the Claims OperationsDepartment, utilizing a multi-departmental approach.

MAJOR DUTIES AND RESPONSIBILITIES:

1. Develops, implements, and continually assessesservice improvement initiatives for all lines of business of operational areasresponsible for.

2. Develops performance standards for Claims Operationsteams, evaluates actual performance against standards, and implements actionplans for improvement.

3. Oversees the compliance of the Claims OperationsDepartment with regulatory and accrediting agencies, including but not limitedto claims payment accuracy and timeliness, appeal processes, and call centerguidelines.

4. Develops and maintains audit processes toassist with claims processing error detection and correction. Works with othermanagers to create a fluid process to deal with provider claims adjustments.

5. Develops training and policy development and goalsand provides oversight to ensure the goals and program are aligned withoperational goals.

6. Creates and promotes a high-performanceculture of service, innovation and results.

7. Responds to and manages internal and externalCorrective Action Plans (CAP)

8. Performs supervisory functions of departmentalrecruiting, hiring, training, discipline and counseling. Develops and maintainsjob descriptions for existing and additional staffing needs. Performsperformance appraisals on direct reports.

9. Provides coordination of external audits,regulatory review, and legal case reviews involving the Claims Operations Department.

10. Collaborates with other management staff toensure that policies, procedures and workflow revisions are consistent acrossthe company.

11. Assists in preparation of annual departmentbudgets.

12. Provides other duties as required or assigned.

All duties are considered essential

COMPETENCIES AND SKILLS:

Demonstrates leadership skills with ability towork collaboratively to produce results across functional teams.

Demonstrates ability to develop and executeaction plans to meet goals and objectives.

Demonstrates managerial and leadershipabilities.

Demonstrates strong analytical, organizationaland communication skills.

Demonstrates ability to communicate clearlyand concisely with Senior Management.

Demonstrates skills in multi-tasking andprioritizing information and projects.

Demonstrated excellent oral and writtencommunication skills required.

Knowledge of all aspects of insurance claimshandling, eligibility and enrollment, and systems configuration.

Knowledge of MS Office products includingWord, Excel, PowerPoint and Outlook.

Evidence of creativity, integrity, initiative,and problem solving.

EDUCATION AND/OR EXPERIENCE:

A Bachelors Degree in Business, Health CareAdministration or other data relevant field plus 7 years managed caremanagerial experience required

OR

Applicants currently enrolled in relateddegree program or with 15 years of highly relevant experience will beconsidered.

Experience working with senior levelmanagement required.

Experience in an HMO, TPA or managed caresetting with Medicare Advantage claims processing required; state andcommercial insurance program claims processing oversight and knowledgepreferred.