Senior Director, Operations, Claims

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

Work Culture:
GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together.
GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP's focuses on 5 Core Values in the workplace:
* Integrity
* Accountability
* Collaboration
* Trust
* Respect

Disclaimers:
* Flexible work schedule is based on job duties, department, organization, or business need.
* Gold Coast Health Plan will not sponsor applicants for work visas.

Travel Required: 5% to 10%

Work Schedule: Potentially work protracted and irregular hours, including potential evening meetings or work unusual hours for meeting attendance or participation in specific projects or programs.

Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodation may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

* Responsible for strategic direction and daily management of key operations areas - Claims Oversight, Encounters, Provider Dispute Resolution, Payment Integrity and ensures the development and management of performance measurement, management controls, critical success factors and key performance indicators.
* Establish and ensure adherence to Medi-Cal, Medicare, D-SNP and GCHP policies and procedures for all functional areas of responsibility.
* Ensure the processing of claims payments adheres to regulatory requirements and that payments are made according to benefit and contract terms; work to minimize the volume of pending and adjusted claims
* Ensure effective and efficient operational processes and regulation adherence including validation that all new policies and procedures are implemented
* Work with the Executive Leader to develop plans for systems and staffing to meet current and future programs, requirements, and initiatives.
* Accountability for plans and budgets of assigned departments monthly and as part of the annual planning process.
* Facilitate data-driven decision making that leads to meaningful actions across operational areas.
* Implement new initiatives and resolve problems that cross multiple departments by forming ad-hoc workgroups and assessing intangible variables, automated processes, manual workflows, and impact to providers and members.
* Work closely with staff, vendors, and peers to set goals, clearly define operations, and develop appropriate performance standards, metrics and reporting tools.
* Oversee the integration of operational departments to maximize the effective use of all resources towards meeting established goals, compliance and quality requirements, and policies and procedures.
* Develops and maintains policies and procedures to meet goals and ensure regulatory/contractual compliance; collaborates in managing regulatory audits and inquiries.
* Lead assigned team of direct and indirect reports. Direct staff development and training, including continuous improvement of knowledge and skill levels of all assigned staff
* Collaborate with internal and external customers and stakeholders to resolve issues and enhance relationships. Ensuring the organization and its mission, programs, products and services are consistently presented in a strong, positive image.

POSITION QUALIFICATIONS

SKILLS & ABILITIES

Education:
* Bachelor's degree (four-year college or technical school) Preferred, Field of Study: Business, Health Care or Public Administration or Equivalent Work Experience

* 10+ years previous experience dealing with Government Healthcare programs, both Medicaid and Medicare.
* 10+ years of experience in Managed Healthcare Operations leadership

Knowledge of:
* Managed Care, particularly Medi-Cal, Medicare and DSNP
* Principles and practices of health care service delivery and managed care, Medi-Cal eligibility, and benefits. Medical billing/coding (CPT, HCPCS, ICD-9 and ICD-10); COB/TPL regulations and guidelines.
* Claims operations and supporting information systems; experience in developing and tracking performance metrics.
* Advanced knowledge of claims regulatory requirements
* Payment Integrity principles and practices
* Principles, practices, techniques, and theories of claims administration and customer service for a government agency serving a diverse social and ethnic population

Computer Skills:

Advanced computer skills included in MS Office products.

Certifications & Licenses:
A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Other Requirements:
* Business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the health care industry.
* Communicate effectively in writing, orally, and with others to convey information, in a manner consistent with job functions.

Competency Statements
* Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
* Management Skills - Ability to organize and direct oneself and effectively supervise others.
* Business Acumen - Ability to grasp and understand business concepts and issues.
* Decision Making - Ability to make critical decisions while following company procedures.
* Presentation Skills - Ability to effectively present information publicly.
* Negotiation Skills - Ability to reach outcomes that gain the support and acceptance of all parties.
* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.