Director, Claim Research & Resolution JHP
Job Location:
Philadelphia, PA - USA
Monthly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
Job Details
The Director Claims Research & Resolution is responsible for leading the strategy governance and execution of complex claims issue identification root cause analysis remediation and resolution. This role oversees a team of analysts and collaborates across Operations Healthcare Economics Configuration Pricing Provider Network and other business areas to drive claims accuracy regulatory compliance financial integrity and continuous process improvement.Job Description
- Provide leadership and oversight for the intake investigation prioritization and resolution of complex claims issues impacting payment accuracy provider experience and operational performance.
- Direct root cause analysis efforts leveraging cross-functional subject matter experts to identify systemic issues and implement sustainable corrective actions.
- Establish and maintain monitoring tracking and reporting processes to identify claims payment and denial trends risks and improvement opportunities.
- Assist with financial impact assessments and remediation strategies including identification and correction of affected claims when necessary.
- Partner with internal stakeholders to ensure timely issue resolution alignment of priorities and accountability for corrective action implementation.
- Build develop and mentor a high-performing team while fostering a culture of accountability collaboration innovation and continuous improvement.
- Directs the daily operations of the provider call center to ensure consistent adherence to service level agreements (SLAs) CMS compliance regulations and state mandates.
QUALIFICATIONS
Education - Required
- High School Diploma/GED
Experience - Required
- 7 years progressive experience in insurance claims administration medical billing or denials and appeals management and
- 5 years experience in a supervisory or departmental management capacity demonstrating the ability to lead large teams of analysts.
Knowledge Skills and Abilities - Required
- Deep operational experience handling complex disputes complex contract terms and medical coding reconsiderations
- The ability to look past individual claim errors to identify systemic flaws in data feeds provider billing habits or internal auto-adjudication systems.
Work Shift
Workday Day (United States of America)Worker Sub Type
RegularEmployee Entity
Health Partners Plans Inc.Primary Location Address
1101 Market Philadelphia Pennsylvania United States of AmericaNationally ranked Jefferson which is principally located in the greater Philadelphia region Lehigh Valley and Northeastern Pennsylvania and southern New Jersey is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65000 people strong dedicated to providing the highest-quality compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrows professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic clinical and applied research. Thomas Jefferson University home of Sidney Kimmel Medical College Jefferson College of Nursing and the Kanbar College of Design Engineering and Commerce dates back to 1824 and today comprises 10 colleges and three schools offering 200 undergraduate and graduate programs to more than 8300 students. Jefferson Health nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age race color religion creed sexual orientation gender gender identity marital status pregnancy national origin ancestry citizenship military status veteran status handicap or disability or any other protected group or status.
Benefits
Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues including medical (including prescription) supplemental insurance dental vision life and AD&D insurance short- and long-term disability flexible spending accounts retirement plans tuition assistance as well as voluntary benefits which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues including those who work less than part-time(including per diemcolleagues adjunct faculty and Jeff Temps) have access to medical (including prescription) insurance.
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Required Experience:
Director
About Company
At Thomas Jefferson University in Philadelphia, PA, we are helping you to redefine what’s possible with innovative and tailored education opportunities.
