Director, Claims - LHB

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Responsibilities:

Coordinating and Executing Deliverables

• Strategically plan, and manage, monitor, track and report performance of the department(s), outsourced vendor and support staff to ensure that exceptional service is achieved on key performance indicators. Oversee delegation of work and adjust plans as needed based on staff availability and business need.
• Oversee related functions and/or support functions, as needed.
• Collaborate with Operations Leader in strategic planning, budgeting, and expense control.
• Initiate, lead or participate in projects as dictated by PSERS or internal business need.

People Leadership and Development

• Oversee or handle personnel matters including mentoring, coaching, motivating, performance management and feedback, recognition, performance evaluation and time tracking of direct and indirect reports.
• Recommend compensation and promotion increases.
• Establish and effectively communicate department goals, objectives, culture and expectations.
• Mentor and develop leaders within the team as well as ensure that those leaders do the same with their staff.
• Collaborate with team including contingent staff to determine staffing needs and succession plans, and take or delegate appropriate action.
• Oversee onboarding and training of new staff and newly promoted staff. Assess ongoing training and development needs and provide opportunities for improvement, as needed.

Operations Management and Support

• Handle increasingly complex claim referrals and over-authority claim audits using internal and external resources as needed. Advise staff or vendor regarding claim processing.
• Oversee resolution of client, member, or provider issues regarding highly visible and increasingly complex claim or service issues.
• Effectively communicate and advise staff on client benefits and unique client handling to ensure proper claim processing. Oversee User Testing to ensure benefits are set-up correctly.
• Oversee review of state/federal legislative and regulatory requirements to determine impact on operational practices. Update and/or implement procedures or documentation, as required.
• Oversee client-initiated auditsfor claims and operational processes.
• Ensure Appeals are maintained with compliance standards

Enterprise Collaboration and Leadership

• Serve as a change agent and leader within the organization to ensure a positive work environment and adherence to corporate values.
• Assist in establishing and maintaining the culture within PSERS Operations.
• Collaborate with staff, as well as enterprise to develop effective policies and procedures. Ensure that policies and procedures are implemented timely and maintained effectively.
• Participate in enterprise-wide work teams and projects. Include staff as needed for both their input and development.
• Present recommendations and make decisions on project teams and in meetings on behalf of department.
• Ensure data sets are monitored for staffing, performance, and accurate claims management.

Job Requirements:

• Bachelor's Degree or 10+ years of related business experience
• Minimum 7 years of medical claims experience in the healthcare/benefits arena
• Minimum 5 years previous management experience
• Strong leadership competence, with proven skills in managing change
• Strong interpersonal and collaboration skills with ability to build consensus and develop solid relationships
• Takes initiative, plans and executes plans well, strategic thinker with ability to multi-task, prioritize, handle pressure and make informed decisions

Preferred Qualifications:

• Bachelor's degree
• Self-Funded Insurance/Benefits and/or TPA experience
• CMS or Medicare experience
• Minimum 5 years previous management experience
• Strong leadership competence, with proven skills in managing change

#LI-TR1

INNN

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Pay Transparency Statement:

At Luminare, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan,pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package forassociates.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plansubject to the terms and the conditions of the plan.

Min to Max Range: