AmeriHealth Caritas Director, Claims Management in New Castle, Delaware

Director, Claims Management


The full time Claims Administrator is responsible for all claims management activities, including any claims management activities that may be subcontracted. The Claims Administrator oversees the timely and accurate processing of claims, encounters forms and other claim information. He/she is responsible for the direction and organization of all operational activities related to the enterprise’s claims function, including claims system processes, claims business rules and prompt, accurate claims payment in accordance with established service-level agreements, stringent quality standards and regulatory requirements. Oversight includes claims systems utilization, capacity analyses, capacity planning and reporting. This role supports the enterprise’s portfolio of product lines, health plans, third party administrators and other potential projects and product types.

Key Accountabilities and Responsibilities

•Directs and ensures accountability for the front-end claims processing, claims projects, and research and analysis. Ensures accountability for root cause analyses of claims issues and implementation of enterprise-wide solutions.

•Meets established regulatory, contractual, and operational standards and goals related to the performance and services of the enterprise claims function, including achievement of time to pay requirements and all internal and external quality levels for both claims processing and claims payment.

•Acts as a liaison with external stakeholders (e.g. high-profile providers) and internal and external clients (e.g. third party administrative clients, health plans, product lines) to assist with and resolve claims issues.

•Engages external partners and provides oversight of the intake of claims through electronic and paper clearinghouses to ensure completeness of claim submissions and diagnose any potential issues.

•Acts as the business owner of all automation of claims processing to optimize the claims system’s capability to auto-adjudicate claims. Owns all related decisions and changes.

•Works with Work Force Management to ensure appropriate capacity and staffing levels for ongoing and future operations.

Required Qualifications and Experience

•Ten to 15 years of experience in health care.

•Ten to 12 years of claims center management experience, with experience managing a large claims staff, preferably in multiple locations.

•Prior staff management experience required with demonstrated success in managing and motivating a large staff, including virtual staff, across multiple locations.

•Previous experience evaluating and developing operational strategy and performance in a metrics-based environment.

•Deep understanding of claims and claims editing systems. Experience with FACETS is preferred.

•Experience working in a large highly matrixed organization with the proven ability to develop internal enterprise relations and external relationships with the medical community.

•Ability to lead teams and direct workflow across several departments and functions.

•Ability to travel approximately 25-30 percent of the time.

Minimum education requirements

•Bachelor’s degree.