Director, Claims Operations
Posted on: 12 Sep 2021
Getzville, NY
Job Description
Position Purpose:
Direct the day-to-day operations of the claims department and ensure accurate and timely processing of members medical claims within established state and company compliance guidelines.
Develop the vision and goals for the claims department in compliance with federal, state and Company guidelines
Oversee and ensure achievement and maintenance of all claims processing standards within established guidelines
Partner with multiple business units, health plans and other stakeholders to establish operational objectives and procedures.
Identify business needs and drive change initiatives to address these issues
Ensure all issues are resolved accurately and timely and implement action plans to address any issues
Identify and implement operational efficiencies and development of “best practice” policies and procedures
Analyze customer impact and respond to complex escalated customer service and claims processing issues to ensure that customer expectations are consistently met
Education/Experience:
Bachelor’s degree or equivalent experience. 7+ years of operations management, financial management or analysis, or claims operations experience, preferably in a managed care and/or Medicaid setting. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff. Experience leading teams in multiple locations a plus. The ideal candidate will have experience leading through change, and be a strategic and innovative thinker.
WellCare
Tampa, FL
WellCare Health Plans, Inc. provides government-sponsored managed care services. The company operates in three segments: Medicaid Health Plans, Medicare Health Plans, and Medicare Prescription Drug Plans (PDPs). The Medicaid Health Plans segment offers plans for beneficiaries of temporary assistance for needy families, supplemental security income, and aged blind and disabled residents; and other state-based programs, such as children's health insurance programs and long-term services and supports programs for qualifying families who are not eligible for Medicaid.
The Medicare Health Plans segment provides Medicare, a federal program that provides eligible persons aged 65 and over, as well as some disabled persons with a range of hospital, medical, and prescription drug benefits; Medicare Advantage, a Medicare’s managed care alternative to the original Medicare program, which offers individuals standard Medicare benefits directly through Centers for Medicare & Medicaid Services; and coordinated care plans that are administered through health maintenance organizations and require members to seek health care services and select a primary care physician from a network of health care providers.
The Medicare PDPs segment provides Medicare part D PDP plans to Medicare-eligible beneficiaries. Its PDP plans offer national in-network prescription drug coverage, including a preferred pharmacy network. As of December 31, 2018, the company served approximately 5.5 million members in the United States. WellCare Health Plans, Inc. was founded in 1985 and is headquartered in Tampa, Florida.
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IndustryHealthcare
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No. of Employees12, 000
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Website
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Jobs Posted917
