Job Summary - Director, Claims Administration
The Director of Claims Administration is responsible for the accurate, timely and efficient adjudication and payment of claims for all product lines at Priority Health. The leader is accountable for claim inventory, claim speed to process, claim auto adjudication rate, claim examiner quality scores, coordination of benefits savings, and third party liability savings.
Essential Functions - Director, Claims Administration
- Lead and develop a high performing claims adjudication team. Assure proper staffing levels.
- Implement goals setting, monitoring and achieving service-levels, medical trend management savings, and unit costs.
- Ensure functions to meet or exceed corporate standards for accuracy and timeliness of claim payment.
- Foster and maintain relationships with other departments to ensure that claims processes and procedures efficiently support other departments, products and overall customer service. Service on corporate committees as directed.
- Initiate process improvement and cost-saving measures. Foster an environment that allows for continuous improvement.
- Develop multi-year roadmaps and meet targets for unit costs, service levels, coaching and development, and other goals as developed.
- Effectively communicate issues and concerns through verbal and written communications. Effectively communicate operational issues and concerns to leadership.
- Ensure compliance with state and federal rules and regulations such as HIPAA, Department of Labor, ERISA, Michigan HMO Legislation, Medicaid, MiChild and Medicare.
Qualifications - Director, Claims Administration
- Required Bachelor's Degree or equivalent education and experience
- 10 years of relevant experience Prior management experience Required
- 2 years of relevant experience Prior claims administration management experience Preferred
- Health care plan claims experience strongly preferred.
Physical Demands - Director, Claims Administration
- Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
- Waist to Waist > 5 lbs: Seldom up to 10 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 10 lbs
- Bilateral Carry > 5 lbs: Seldom up to 10 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 10 lbs
- Pulling Force > 5 lbs: Seldom up to 10 lbs
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Finger/Hand Dexterity: Frequently
- Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
- On-demand pay program powered by Payactiv
- Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
- Optional identity theft protection, home and auto insurance
- Traditional and Roth retirement options with service contribution and match savings
- Eligibility for benefits is determined by employment type and status
Primary Location
SITE - Priority Health - 1239 E Beltline Ave NE - Grand Rapids
Department Name
Quality and Payment Integrity Administration - PH Managed Benefits
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
9:00 a.m. to 5:00 p.m.
Days Worked
Monday through Friday
Weekend Frequency
N/A
CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
