The Director of Claims Operations develops, directs, implements, and oversees the management and payment of claims for all lines of business at Denver Health Medical Plan. Develops and implements all related processes and manages the external benefit configuration vendor. Responsible for managing the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with contracted fee schedules and covered benefits as specified. Hires, supervises, and develops all staff. Actively participates as a member of the Plan’s Operations Management Team.
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has
Education: Bachelor’s degree is required.
Experience: Typically, five to seven years of claims management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines. Strong experience in managing claims system development, configuration, and maintenance. Experienced in managing claims processing for Medicare, Medicaid, CHP+, Large Group Commercial, and Healthcare Exchange. Demonstrated track record in creating approaches, policies, and procedures to ensure effectiveness of the claims payment and adjudication process at a health plan.
Knowledge, Skills & Abilities: Solid system development and evaluation abilities, effective leadership and management, and outstanding written and oral communication skills are required. Experience and proficiency with Trizetto QNXT is highly desired. Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services (“CMS”) and the Colorado Department of Health Care, Policy & Financing (“HCPF”) is required. Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA. Knowledge of bundled payments, risk-sharing, and provider capitation is essential. Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems. Able to perform effectively in a leadership role and evaluate processes for efficiency. Experienced in supervising staff and ensuring key tasks and goals are met on a timely basis.
Certificate/License/Registration: All Certifications and Licenses required for this job must be kept current as a condition of continued employment.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver’s 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado’s primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
“Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.”