View Our Website View All Jobs

Director of Claims-International Claims Management

Primary Role & Responsibilities:

  • Provides leadership, development and mentoring of the Claims Management and staff by creating a culture of high performance that is driven by strategic objectives, service excellence and the company’s goals
  • Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims processing and provider inquiries (written or verbal)
  • Oversees vendor relationships pertaining to Claims processes (i.e. Com-Com)  
  • Generates data in order to track and report on results compared to operational and service level goals and other trends as required
  • Creates and manages departmental budget and meets financial targets
  • Maintains confidentiality of all patient information, as per HIPAA guidelines
  • Analyzes, tracks and trends claims data in order to provide analysis of data / results along with action steps to ensure operational efficiencies are maintained

Claims Adjudicator Duties/Skills:

  • Generates standard reports for the functional area and tracks all employee performance for high volume transaction area
  • Oversees day to day employee metrics and Claims to Work performance
  • Conducts auditing on claim adjudication activities
  • Evaluates adjusted claims against original claim processing activities to identify processing errors undetected during initial processing
  • Provides input into adjudication materials and their revisions to ensure quality outcomes during auto and manual adjudication
  • Conducts adjudicator audits of processed claims against guidelines, policies and procedures

Minimum Knowledge, Skills and Abilities:

  • Prior experience in healthcare and insurance field for processing international medical claims. Experienced with UB’s & HCFA’s as well as superbills.
  • Minimum of a BA/BS degree with at least five (5) years of relevant professional experience, and the following:
  • Strong knowledge of medical coding (ICD-9, ICD-10, CPT)
  • Maintains current knowledge of coding issues which includes accurately coding within CMS and carrier compliance guidelines, laws and policies from CPT, HCPCS and ICD-9/ICD-10 coding manuals.
  • Previous Adjudication or Claims Adjusters License is a plus
  • Extensive knowledge of claims policies and procedure
  • Experience in developing and tracking performance metrics
  • Experience with managing US & International Claims
  • Experience working with large US/International carries in a similar role
  • Experience with Fraud, Waste & Abuse
Read More

Apply for this position

Apply with Indeed
Attach resume as .pdf, .doc, .docx, .odt, .txt, or .rtf (limit 5MB) or Paste resume

Paste your resume here or Attach resume file