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Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

The Senior Director, Claims & Provider Reimbursement, is responsible for oversight of health plan claims administration. The position will develop, maintain, and optimize process flows to maintain claims payment accuracy.

Job Description

Key Outcomes:

+ Drives quality, timely claims processing to allow the health plan to achieve regulatory compliance, robust financial management and product strategy outcomes

+ Oversee strong inventory management processes and enhance auto adjudication

+ Delivers strong vendor oversight to optimize system processing to improve efficiency and accuracy; pursue new vendor opportunities including Request for Information (RFI)/Request for Proposal (RFP) as deemed appropriate

+ Collaborates with business and IT teams to ensure system and operational readiness for system fixes, configuration, and project rollouts impacting claims processing

+ Ensures operational readiness, testing, training, reporting, and communications are in place for claims processing updates

+ Acts as business owner for claims processing and edit vendors, ensuring oversight of vendor, including day-to-day management, roadmap reviews and joint operating committee management

+ Oversees, develops, and maintains documentation for claims and configuration processes and procedures with appropriate controls, reporting and quality assurance

+ Develops work intake mechanisms, exploring and implementing tools to manage claims processing tickets, prioritize backlog and assess different work types (i.e., reporting, configuration, project vs. production fixes, etc.)

+ Remains up to date on industry trends and advancements in claims provider reimbursement and system technology to identify opportunities for improvement

+ Supports regular audits and quality checks to ensure data accuracy and system performance

+ Oversees the research, development, implementation, ongoing operational maintenance and administration of provider payment methodologies and fee schedules for all provider types in support of provider contractual arrangements

+ Supports the development and integration of provider payment policies and guidelines applicable to institutional and professional reimbursements and in concert with the Organization's products and member benefits

+ Maintains all institutional and professional reimbursement methodologies leveraged by the organization. This includes demonstrating deep knowledge in industry standard payment methods

+ Demonstrates working knowledge in the design and roll out of alternative payment methods that are focused on an incentive-based pay for value approach. This will require partnering cross organizationally to support the development of these new programs, and direct the operational activities necessary to stand them up

+ Researches and provides recommendations on development of new or enhancements to existing reimbursements in conjunction with corporate and contractual initiatives including sound financial modeling/impact analyses

Education/Experience:

+ Bachelor’s degree required or equivalent combination of relevant education, training and experience ; Master’s in business administration or comparable advanced degree strongly preferred

+ CPC Preferred

+ 10+ years health plan management experience required

+ Experience managing vended system applications

+ Experience with test plan development, strategy, and execution

Skills/Knowledge/Competencies (Behaviors):

+ Demonstrates an understanding of and alignment with Martin’s Point Values.

+ Maintains knowledge and understanding of reimbursement agreements as well as claims and billing practices that impact cost and utilization data.

+ Detailed knowledge of applicable regulatory and accrediting body standards (National Committee of Quality Assurance (NCQA), Centers of Medicare and Medicaid Services (CMS))

+ Develops and maintains positive, effective working relationships with colleagues, vendors, and other internal and external customers.

+ Excellent workflow and inventory management skills.

+ Excellent problem solving, quantitative and analytical skills with the ability to assess performance against metrics.

+ In-depth technical knowledge and ability to learn new technologies; knowledge of the Software Development Life Cycle (SDLC).

+ Ability to manage, organize, and prioritize workload in a timely accurate manner.

+ Ability to manage multiple competing demands and function independently.

+ Knowledge of industry standards for claims and enrollment configuration, reporting and analysis.

+ Knowledge of benefit coverage and servicing members, providers, and the DoD, CMS/ Medicare Advantage, and ME state insurance coverage.

+ Knowledge of managed care computer systems, features, and reporting.

+ Demonstrated interpersonal, communications, operational, team building, and quality improvement skills.

+ Critical thinking: can identify root causes and implement short- and long-term sustainable solutions.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]