Director, Claims Process Optimization – Facets Required

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $113k - $197.7k / year

⏰ Full Time

🔴 Lead

👔 Director

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Lead the design, implementation, and ongoing oversight of automation and artificial intelligence capabilities across claims operations • Identify opportunities for intelligent automation, build business cases, guide delivery with configuration, information technology, and vendor partners, and validate sustained production performance • Maintain oversight of claims adjudication and adjustment workflows • Monitor the operating budget and manage vendor performance • Lead a team of managers, analysts, and process specialists • Own operating performance, including inventory, throughput, auto-adjudication rate, accuracy, and regulatory turnaround time • Build and maintain the claims automation and artificial intelligence roadmap • Quantify and report benefit realization against pre-deployment baselines • Analyze workflows using process mapping, time studies, and production data • Build business cases for automation and improvement investments and report actual performance • Track cost per claim and capacity utilization to inform staffing, sourcing, and automation sequencing • Develop and monitor operating budgets for assigned functions and technology initiatives • Direct root cause analysis and resolution of recurring defects with upstream owners • Maintain procedures, process controls, and audit evidence for internal, state, federal, and delegated reviews • Run daily production reviews, weekly operating reviews, and monthly business reviews • Manage outsourced, offshore, and technology vendors against service levels, quality standards, and delivery commitments • Participate in vendor selection, statement of work development, and renewal decisions • Perform other job-related duties as requested

🎯 Requirements

• Bachelor's degree in business, health administration, data analytics, or a related field required • Equivalent years of relevant work experience may be accepted in lieu of required education • Seven (7) years of health plan claims or healthcare operations experience required • Five (5) years of leadership experience required • Practical understanding of automation and artificial intelligence capabilities applicable to claims work • Working knowledge of claims adjudication platforms, provider reimbursement methodologies, and standard code sets including CPT, HCPCS, ICD-10, and revenue codes • Strong analytical skills • Proven change leadership skills • Strong financial acumen • Clear written and verbal communication, including the ability to present technical detail and operational risk to executive audiences • General office environment; may be required to sit or stand for extended periods of time • Travel is not typically required

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support • Remote work arrangement