Director Claims Payment
DentaQuest - Boston, MA

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Determine claim processing methodologies aligning to business, clients, and contractual, state and federal regulations. Lead and direct the activities of the Claims Operations Team to achieve superior operational performance and process excellence in claims processing and payment through an integrated process of operational, system, quality, and resource management that meets or exceeds member, customer, and provider expectations and is consistent with corporate goals and standards. Determine and direct appropriate development of processing system ensuring claim processing functionality meets all required standards.

Responsible for establishing and maintaining claim processing protocols in accordance to corporate goals ensuring all claims are processed accurately and within service level agreements.

Advise and direct strategic claim processing workflow and policy

Address escalated claim disputes. Make financial decisions around adjustments and exceptions that meet business, provider, client, and auditing requirements

Manage end to end claim payment, including but not limited to: claim payment process, claim payment data, claim payment solutions, cross departmental management, and research of payment files

Translate existing business needs into future process redesign and/or technology solutions

Influence various constituencies, including clients, on strategic change to business processes

Solution escalated claim payment & processing challenges from all constituents

Collaborate with finance, dental management, and UM to understand and positively influence loss ratios and access to care

Lead change initiatives ensuring leading edge processes and solutions within operations

Partner with the SMEs throughout the planning, analysis, design, testing and deployment phases to facilitate business requirements definition, business priorities, solution identification, and solution development lifecycle. Operate as SME in appropriate instances

Understand the link to upstream and downstream Operations, Systems, and Technology

Capture the tactical and strategic business goals that provide traceability through the organization

Provide input and approval for all system changes

Identify enhancements to current system platform to gain efficiencies

Ensure key enhancements are executed

Drive strategic initiatives such as automation and self service

Identify system defects impacting operational quality and execute appropriate system resolutions

Troubleshoot operational system issues and develop solutions

Establish meaningful goals and metrics for all pertinent functions as they pertain to both internal and external expectations and requirements

Influence new membership growth and existing membership retention through effective management of claim & payment services

Actively participate with Directors and the Executives in developing annual and ongoing corporate goals and develop the strategic and tactical initiatives to implement successfully.

Participate effectively as an integral member of the prioritization committee(s) to prioritize corporate initiatives, and manage company-wide expectations through effective project process, monitoring, and communication

Ensure that the Executives receive the appropriate updates and notification of potential business risks by providing and maintaining standardized reporting of metrics, statistics, accomplishments, priorities and issues

Implement and monitor regular redesigned processes to ensure smooth and measurable implementation

Managed daily forecast to ensure proper utilization of labor and overtime to achieve the maximum service levels within budget

Complete all employee management duties, including but not limited to: hiring, training, terminations, corrective active plans, reward and recognition, preparation and presentation of performance evaluations assuring compliance with DentaQuest’s policies creating an environment of performance and operational excellence

Influence staffs to achieve organization & corporate objectives while helping employees understand current and new business directions

Anticipate resource needs, establish appropriate priorities and eliminate unnecessary functions

Establish and maintain functional and technical knowledge of Windward and enabling technologies to be able to respond to unique requests made by clients; work collaboratively with clients to meet their needs without compromising DentaQuest principles

Build strong, collaborative working relationships with other functional areas across the Enterprise to ensure all processes and work interdependencies are identified and addressed on an ongoing basis. Work closely with Sales, Client Services, IT, and Finance to identify expectations and proactively implement processes and procedures to ensure customer and business needs are exceeded

Ability to be business lead in understanding payor systems requirements and functionality.

Ensure regulatory and legal compliance within department

Complete all employee relation duties, including but not limited to: hiring, terminations, corrective active plans, reward and recognition, preparation and presentation of performance evaluations assuring compliance with DentaQuest’s policies

Recognize and promote diversity in all aspects of resource management

Effectively perform Leadership functions for varied corporate initiatives

Other duties as assigned

Meet with clients and represent all of operations within sales, implementation, and maintenance phases of relationship

Conduct client presentations of system and processes

Required Skills

Required Experience

Bachelor Degree with 10-15 years claim processing/healthcare experience

Technology acumen required

10+ years previous management experience

Excellent data analytics and problem solving skills

Knowledge of business projects and concepts through direct assistance and management

Ability to present and interact with clients regarding all operational aspects of DentaQuest

Self managed with little to no direction

Ability to manage project resources that do not have a direct reporting relationship

Strong computer skills including Word, Excel, and previous claim processing systems

Demonstrated ability to manage production/transactions

Strong business acumen

Ability to prioritize and organize multiple tasks and manage competing priorities

Excellent math capabilities

Ability to make appropriate decisions within tight timeframes

Excellent communication skills: written, verbal and interpersonal

Ability to work well with others at all levels of the organization.

Ability to manage multiple priorities and adapt to changing conditions

Demonstrated achievements in project management leadership

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