Director Claims Cost Containment
Excellus BlueCross BlueShield - New York

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The Director, Cost Containment plans, develops, recommends, and monitors procedures and systems to be used to improve medical claims payment accuracy for Health Plan, Lifetime Health Medical Groups, Monroe Plan, Safety Net, and Medicare. This position develops and executes the cost-containment strategy to include all medical claims recovery opportunities and cost containment initiatives as a function of cost avoidance. Incumbent directs programs to ensure operational claims transactions are consistent with contractual terms in provider and employer contracts, as well as medical policies. Directs quality focused analytical support with the aim of resolving and preventing systemic claims cost issues. In addition, provides senior management with evaluations and recommendations on the reliability and the integrity of financial and operating information as applicable to claims cost containment; compliance with policies, plans, procedures, and governmental laws and regulations; adequacy of means established to safeguard corporate assets, the economy and efficiency with which resources are employed; and the realization of objectives and goals for operations or programs.

Essential Responsibilities/Accountabilities:
• Leads all aspects of the Claims Cost Containment Department with overarching goal and objective to find errors, respond to trends, determine root causes, recommend fixes, increase transactional accuracy, and recover claim over-payments.
• Develops, articulates, and implements the corporate claims cost containment/recovery strategy:
o Based on competitive Intelligence with respect to results
o Based on knowledge of industry tools
o To ensure efficiency, common methodology, and common objectives.
• Conducts all business with the goals and objectives designed to meet national claims benchmarks in: financial accuracy, payment accuracy, processing accuracy, and overpayment recovery.
• Applies cost containment efforts on a continuing basis to meet the financial and performance goals of the organization.
• Oversees the root cause analysis of errors as it pertains to operational transactions to ensure future claim payments are paid accurately and consistently.
• Collaborates with other divisional management to identify areas of improvement, remediate system issues, and support corporate goals and initiatives.
• Creates and implements strategies for the consistent recovery of overpayments and errors.
• Creates strategic methodologies to ensure a consistent approach is followed in determining the root cause and/or effectively communicating claims cost quality issues that need to be addressed.
• Orchestrates and recommends action plans, processes and policies for the recovery of funds based on a multi-disciplinary approach that takes into account the full appreciation of all events, circumstances, and decision making that initially lead to the overpayment.
• Responsible for understanding the problems and unique situations that may represent a claims cost control risk to the Health Plan.
• Focuses on closed-loop recovery trends and methods to remediate thereby shifting trends to cost containment demonstrating year over year improvements.
• Notifies Corporate Audit and other affected areas of management as needed; especially when those situations cross functions and/or divisions.
• Coordinates, integrates, and oversees collaboration efforts of the Claims Cost Containment functions with all other LTHC company functions as applicable.
• Oversees Health Plan, Lifetime Health Medical Groups, Monroe Plan, and Safety Net recovery efforts. Assures that employer group, DOH, NYSID and the Attorney General requirements are met as related to contractual management practices.
• Conducts cost benefit analyses regarding new review processes.
• Develops and implements department goals and corresponding action plans, and monitors performance against these. Assures that progress reports are accurate and timely.
• Conducts trend analysis, forecasting, and identification of financial and transactional impacts of contract provisions, settlements and process changes across all regions and lines of business before they are finalized.
• Develops and manages department executive summaries relative to performance measurements, i.e. Savings reports, closed loop reporting, ROI analyses, inventory management, and productivity reports.
• Ensures all financial-operational data results are complete, accurate, timely, reliable and relevant.
• Acts as an internal consultant on special operational and corporate projects related to cost containment/recoveries
• Serves as a standing, active member on Company Committees as assigned.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management

Minimum Qualifications
• Bachelor's degree in Accounting, Finance, Business Administration or related field with a minimum of 8 years of progressive management experience with health care services and insurance claims, supported by a thorough knowledge of managed care principles, computer applications and corporate benefits and riders. In lieu of degree, a minimum of 15years of progressive management experience with health care services and insurance claims, supported by a thorough knowledge of managed care principles, computer applications and corporate benefits and riders.
• Minimum of 5 years in a leadership role
• Must possess strong leadership skills as well as the ability to effectively direct people and multiple projects. Must possess strong and effective analytical and problem-solving skills along with the capacity to identify and understand business objectives and associated risks. Must maintain a high level of objectivity and independence
• Experience managing large scale change initiatives
• Ability to develop and maintain constructive relationships with internal customers, the provider community, program administration and other Health Plans.
• Must possess excellent verbal and written communication, human relations and negotiation skills as well as the ability to interact effectively with individuals at all levels of management throughout the organization. Fully proficient to present findings and recommendations to senior management.

Physical Requirements

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

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