Senior Director, Claims & Payment Integrity

This is a fully remote position, open to applicants in Maine.

📋 Description

• Accountable for overseeing the administration of health plan claims and ensuring payment integrity functions.

• Design, implement, and refine process flows to ensure accuracy in claims payments.

• Promotes timely and high-quality claims processing to meet regulatory standards and ensure effective financial management.

• Supervise robust inventory management practices and enhance automated adjudication processes.

• Provides comprehensive vendor oversight to optimize system processing for improved efficiency and accuracy.

• Works collaboratively with business and IT teams to guarantee system operational readiness.

• Ensures that operational readiness, testing, training, reporting, and communication protocols are established.

• Serves as the business owner for claims processing and editing vendors.

• Oversees the development and maintenance of documentation related to claims and configuration processes.

• Creates work intake mechanisms and deploys tools for managing claims processing tickets.

• Assists in regular audits and quality checks to ensure data accuracy and system performance.

⛳️ Requirements

• A Bachelor’s degree is required.

• A Master’s degree in business administration or a similar advanced degree is highly preferred.

• A minimum of 10 years of experience in health plan management is required.

• Demonstrated experience in managing vendor system applications.

• Proficient in developing, strategizing, and executing test plans.

🏝️ Benefits

• A workplace culture built on trust and respect.

• Ongoing opportunities for continuous learning.

• A range of professional development opportunities.