Description and Requirements

The Director, Claims and Provider Payment Modernization will apply skills at the intersection of business and technology to plan, organize, and implement initiatives supporting our Claims and Provider Payment Modernization program. S/he is a thought leader and implementer of our approach to enabling Operations staff to transition from legacy systems and processes to future-state, streamlined models and procedures. This role is instrumental in ensuring overall adherence to regulatory expectations while improving the overall quality of work output. This role requires cross-functional work to ensure department and corporate strategies are executed and achieved enterprise-wide.

Duties & Responsibilities:

• Assists in the development of strategic plans to ensure modern and efficient claims processing across the entire lifecycle with a focus on a unified, streamlined experience for both providers and operations staff
• Works closely with technology and business leadership to support the evolution and operation of a variety of digital claims capabilities on our modernization roadmap
• Analyzes project needs and determines people, process, and technology resources needed to meet objectives and achieve desired outcomes
• Ensures the successful completion of current and long-range department goals and objectives and monitors results on an ongoing basis, adjusting plans and performance expectations to achieve targeted performance improvement results
• Acts as a liaison between business and technology teams, ensuring accurate translation of ideas and concepts between the parties to align strategy
• Takes initiative, thinks analytically, and works independent of supervision as appropriate or needed
• Builds, manages, develops, and continuously improves the claims experience to meet the diverse and dynamic needs of a growing, evolving organization
• Develops an effective team through hiring, training, coaching, and providing ongoing and constructive feedback
• Communicates results to executive leadership using standardized reports, dashboards, and frequent verbal updates through participation in management meetings and operational review processes
• Develops, formulates, recommends, and implements decisions regarding policy, standards methods, procedures, and functions
• Ensures all NY state and federal compliance, audit and regulatory requirements are met
• Performs other duties as necessary or assigned

• Bachelor's degree from an accredited institution or equivalent work experience
• Prior experience instituting change initiatives within an operational unit
• Proven ability to develop strong interpersonal relationships with key stakeholders, with experience communicating and influencing at the senior leadership level.
• Successful track record developing creative, workable strategies and tactics to accomplish division, corporate and plan goals
• Work experience requiring written and verbal communication that is clear, concise, grammatically correct, and professional

• Master's degree or MBA from an accredited institution
• Prior experience with claims and provider payment operations in a healthcare payor setting
• Experience setting departmental strategy, communicating, and influencing impact and progress to senior leadership
• Experience with Medicare/Medicaid and Commercial Healthcare
• Strong leadership capability with experience leading change, establishing a business strategy, setting performance targets/benchmarks and using metrics, team engagement protocols and innovative problem-solving techniques to drive execution of cost, quality and productivity areas for a large operation
• Demonstrated understanding and practical experience using Agile methodologies. Exposure to Scaled Agile (SAFe) preferred