Director of Operations (TPA Claims & Intake)

eClusive - Eden Prairie, MN (30+ days ago)


eClusive is a third-party administrator (TPA) that provides back-office functions for capitated health plans. Back-office functions include but are not limited to claims adjudication, member enrollment and reporting, data reporting submissions, and financial reporting. eClusive’s sister company, Mediture, develops healthcare information technology software solutions for managing care coordination for capitated health plans. Both companies work closely together to provide integrated and intuitive products to our health plans.

eClusive’s company goal is to seamlessly handle our client’s back-office functions to allow the plan to financially thrive and grow so they can focus on member care coordination. eClusive is looking for an industry expert that is energetic and entrepreneurial to help us build and optimize our client’s back-office workflows.

POSITION SUMMARY: The Director of Operations oversees a team of 16 staff to manage the claim adjudication process for customer’s health plans. The Director of Operations will have responsibility for overall management of client relationships and will work with the Executive Team to deliver best-in-class service and proactive solutions.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Support implementation and operations of 10+ customer accounts.
  • Lead weekly operations meetings and 1:1 coaching with team members.
  • Oversee healthcare claim processing for appropriateness and completeness of information in accordance with accepted coverage guidelines, ensuring all government and state regulations are consistently met.
  • Ensures timely delivery of claims adjudication and payment to customer’s providers.
  • Work with Claims Analysts who approve, pend, or deny payment according to the accepted coverage guidelines; set up fee schedules and contracted rates in TruChart system.
  • Maintaining external and internal customer relations by interacting with staff regarding claims issues. Providing service as the key contact for clients and working as directed with customer’s providers.
  • Assist in training and onboarding new staff as needed; assist the management team in problem resolution, planning and overseeing workflows; testing and preparing documentation and updating current documentation; as well as providing suggestions and recommendations to improve workflows and departmental efficiencies.
  • Responsible for customer service call center performance for clients and third-party vendors.
  • Assists with writing and revising policies and procedures regarding claims management.
  • Responsible for working with clearing house vendors to ensure performance within industry standards as required by the benefit plan contracts.
  • Work with HR regarding personnel activity concerning hiring, training/development, and evaluation of staff performance.
  • Stays up-to-date on Health Plan Operations and Medicare changes through HPMS notifications and other venues.
  • Partner with Sales to support prospective sales presentations and respond to RFPs.
  • Occasional travel to customer sites for training.
  • Customer retention, upselling and maximizing existing use of TruChart.

DESIRED SKILLS:

  • Specific knowledge of claims, enrollment, and premium business processes in a commercial, Medicare, or Medicaid health plan/TPA organization.
  • Expert in Medicare and Medicaid reimbursement rules and procedures as well as ad hoc reimbursement rates for specific plans.
  • Robust understanding of health care payment cycle.
  • Knowledge of industry standard health data code sets such as ICD-9/ICD-10, CPT/HCPCS, and Revenue Codes.

QUALIFICATIONS:

  • Dynamic interpersonal skills that will enable developing strong rapport with clients.
  • Thorough knowledge of Excel and other MS Suite products.
  • Ability to speak clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions.
  • Ability to perform multiple tasks simultaneously.
  • Responds promptly to customer needs; Responds to requests for service and assistance.
  • Interprets and presents numerical data effectively.
  • Ability to work both independently and with the team.
  • Ability to display enthusiasm in working with members and staff to enhance their interest and to support the goals and objectives of the company.
  • Leadership, communication, interpersonal skills coupled with strong customer driven orientation.

MINIMUM REQUIREMENTS:

  • Bachelor’s degree or equivalent relevant prior work experience.
  • A minimum of 8 years’ experience with a health plan, hospital billing, or third-party administrator.

Working Here

Mediture/eClusive offers competitive compensation and benefits. As an employee, you will contribute to highly valued products and business objectives of end users in a growing industry. You will be part of a professional and positive environment and have excellent opportunities to make an impact. To join our successful team, please apply with your resume, cover letter, and any salary expectations.

Mediture is an Equal Opportunity Employer.

Employment is contingent upon a successful background check.

Expected Hours of Work: This is a full-time position with an expectation to work an average of 40 hours per week, and an ability to be available outside of normal business hours to meet customer expectations on an ad-hoc basis. Normal business hours are between 8:00 a.m. to 5:00 p.m.

Travel: Up to 10%.

Supervisory Responsibility: This position will supervise 16 team members.

Environment: This job operates in a professional, dress for your day, office environment. This role routinely uses standard office equipment such as computers, phones, printers, and filing cabinets.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to travel; use hands to finger, handle or feel; and reach with hands and arms.

Who Is Mediture?

Mediture is a leading provider of healthcare software that supports the mission of helping elderly and vulnerable populations stay in their home. Mediture software solutions facilitate care management, benefit plan management, and financial oversight in capitated healthcare markets. Mediture TruChart Health Plan Management, Electronic Health Record, and Analytics solutions empowers organizations to track measurable outcomes to support the specific needs of the population they serve. Based in Eden Prairie, MN, Mediture has a national client base delivering care for populations with complex healthcare needs. As a driven team, Mediture works together to deliver solutions that solve customers' challenges and support vulnerable populations.

Job Type: Full-time

Experience:

  • UB04 or 1500: 3 years (Preferred)
  • ICD-9/ICD-10: 3 years (Preferred)
  • health plan, clinical/hospital billing, or TPA: 8 years (Required)
  • CPT/HCPCS: 3 years (Preferred)
  • Revenue Codes: 3 years (Preferred)

Education:

  • Bachelor's (Preferred)