Associate Director of Claims Operations
Partnership HealthPlan of California - Fairfield, CA

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POSITION PURPOSE

Daily management of the Claims Customer Service Manager and Claims Managers. Manage daily operations of claims call center and examining units.

ESSENTIAL DUTIES AND RESPONSIBILITIES
  • Management of the Claims Managers and Customer Service Manager and their functional areas.
  • Interviews and participates in the selection of qualified candidates for open positions within the claims operations area. Evaluates performance and provides developmental opportunities for claims staff. Counsels performance issues when needed. Reviews and signs time cards.
  • Review and approve daily, weekly, and monthly claims operation reports.
  • Ensure compliance with regulatory requirements for claims call center and claims examining functions.
  • Review and approve quarterly compliance reporting. Ensure compliance with department internal quality indicators.
  • Review and analyze claims and call center trend reports and recommend changes to the Claims Director.
  • Review and approve electronic and Imagenet claims loads from IT department daily and weekly.
  • Reviews and sign adjustments requests and high dollar claims within established guidelines.
  • Reviews all claims department Special Decisions and makes recommendations to Claims Director.
  • Reviews department policies and procedures, recommends changes for more efficient operation, drafts new policies/procedures for Director’s review, communicate changes and updates to staff.
  • Participates in operational meetings both on and off site as required.
  • Participates in PHC audits and in audits of delegated entities.

SECONDARY DUTIES AND RESPONSIBILITIES
  • Leads or participates in special projects and assignments as needed.

HIRING CRITERIA

Education and Experience

Prefer Bachelor’s degree in related field; minimum five (5) years management experience in a claims environment; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Knowledge of HMO operations. Knowledge of Federal Medicaid and Medicare programs. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance

Based

Competencies

Demonstrate excellent leadership skills with ability to establish and motivate staff to achieve goals and objectives. Excellent interpersonal skills to ensure effective operations, meeting deadlines and standards. Excellent written and oral communication skills. Excellent customer service skills.

Work Environment And Physical Demands

Ability to use a computer keyboard and 10-key calculator. More than 30% of work time is spent in front of a computer monitor. Ability to move about the department freely to assist with operational functions as needed.

All HealthPlan employees are expected to:
  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, education factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive, or work environment change.