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Director of Claims Operations

Virtual (80%-100% Travel)

Summary

PPT Solutions is a premier provider of Customer Experience and Business Optimization Solutions.  We work hand-in-hand with our clients' senior executives of Fortune 1000 companies and government agencies to transform their organization and their industries with our combination of strategy, technology, operations, and change management capabilities.

Job Description

The PPT Solutions team is seeking a Director of Claims Operations for our client. This position is responsible for providing leadership and managing the overall operations, processes and resources of the Claims Department. The Director of Claims Operations interacts with Client stakeholders to understand their needs and collaborates with internal teams to help design solutions and supports delivery.

Essential Duties

  • Directs and coaches management team within the Department to ensure that claims are adjudicated in an efficient, accurate and timely manner and in accordance with Federal/State, Regulatory and Plan standards.
  • Develops and reviews workflows and processes to ensure that they support corporate goals and meet the business needs of the department.
  • Makes recommendations for improvement when necessary.
  • Creates and reviews reports on a regular basis to ensure that claims are processed within time frames set by regulatory agencies.
  • Develops and implements process audits and reports results on a monthly basis to measure accuracy and identify opportunities for training and development.
  • Maintains statistical results for reporting to the Compliance Committee on a monthly basis.
  • Works with IT Department to analyze pended claims, document trends and review manual processes to present opportunities to enhance system performance and increase the auto-adjudication rate.
  • Makes recommendations for improvements to system configuration.
  • Reviews auto-adjudication reports on a monthly basis and tracks progress.
  • Sets quarterly goals and implements process modifications to meet or exceed goals.
  • Ensures customer’s complaints and inquiries are resolved timely and accurately.

Experience and Skills

Minimum of 4 years of relevant functional work experience as a Director of Claims Operations in a dual plan Healthcare provider.  
  • Bachelor’s degree and/or equivalent work experience
  • Strong mentoring and relationship building skills with the ability to manage group and interpersonal conflict situations.
  • Excellent oral and writing skills characterized by the ability to communicate thoroughly and clearly to a range of reading and comprehension skill levels.
  • Quantitative and qualitative analytical skills required to understand business processes and functions, compile and interpret appropriate data, and identify and solve problems.
  • Computer Skills: Microsoft Suite products, Facets, Altruista and other claims management software.
  • Experience in evaluating, developing, and implementing operating procedures and systems effecting the business environment, with the ability to suggest changes and the authority to make them.
  • Demonstrated ability to work resourcefully and creatively, to think independently, and to exercise independent judgement in originating or developing techniques or programs in a complex and dynamic environment.
  • Strong problem-solving skills and demonstrated ability to optimize efficiency and performance.
  • Commitment to the corporate mission, vision, and values.
  We offer a highly competitive compensation structure that will allow you to be rewarded for the contributions you make.  If you thrive in an environment that is collaborative, challenging, and will provide you the opportunity to expand your skills – come talk to us.  We’d welcome the opportunity to get to know you and allow you to learn more about us.   We are an equal opportunity employer committed to providing a diverse environment.   The above information has been designed to indicate the general nature and level of work performed by employees within this classification.  It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.