Description and Requirements

Job Profile Summary The Director of Reimbursement Configuration is responsible for developing, directing and coordinating the configuration of claim reimbursement patterns and strategies across Healthfirst's technology platforms in collaboration with Provider Contracting, Claims Operations, Provider Data Management, Clinical Operations, Payment Integrity, and Information Technology. The Director leads forums and meetings with leadership from across the enterprise to develop effective and efficient reimbursement configuration solutions to achieve business needs and objectives and maintain alignment with claims payment and reimbursement policies. The Director analyzes complex configuration defects and recommends strategies for successful and timely remediation. The Director leads a team of managers and analysts to ensure accurate, complete, and timely configuration of contractual terms, coding and rate updates, and fee schedule creation and maintenance. The Director oversees team performance, configuration production, and quality metrics to ensure that project and department goals are met. The Director also collaborates across other configuration teams to ensure all required configuration aspects are accounted for in planning and operationalizing accurate claim pricing and adjudication, including benefits, authorizations, reference data, claims editing, regulatory requirements, reimbursement policies, and overall claim system functionality. The Director serves as the authoritative source for all claim reimbursement patterns and payment logic across the business. Recognized as an influential leader, the individual at this level functions as a cultural ambassador and strategy driver for Healthfirst. He/she promotes and reinforces behavior that is consistent with Healthfirst's desired culture and fulfills his/her role in aligning Healthfirst's strategic initiatives with desired organizational outcomes.

• Drive flexible, repeatable and scalable claims configuration design and implementation processes with industry best-practices
• Engage directly with other operational teams and leaders to provide input on the scope, approach, and timing of configuration work
• Assess upstream and downstream impact of configuration and policy changes to proactively identify and mitigate risk
• Manage interdependencies across other configuration units and business areas to ensure delivery timelines and project deadlines are met
• Identify and resolve inconsistencies between system configurations and reimbursement contracts and policies
• Maintain effective and consistent configuration testing protocols and quality controls
• Manage and monitor team performance, production and quality
• Establish structure for ongoing education, training and knowledge share across team
• Prepare and present updates to the business and senior executives on configuration strategies, activities, and metrics
• Lead and support company-wide initiatives
• Work with internal and external parties to ensure claim payment logic and business rules are well understood and administered appropriately
• Actively support all Compliance and Regulatory requirements with appropriate policies, processes, reports, and audit support.
• Additional duties as assigned.

• Bachelor's Degree from an accredited institution or equivalent work experience
• Proven experience in health insurance focused on claim configuration and reimbursement processes
• Proficiency in provider contract reimbursement terms and code sets (HCPCS, ICD10, DRGs, CPT, etc.), and claims processing practices
• Knowledge of medical claims and adjudication procedures, including the application of reimbursement and medical policy guidelines and contract pricing
• Knowledge of claim payment methodologies and regulatory frameworks governing health plan reimbursement methods in Medicare, Medicaid and commercial insurance markets
• Experience leading complex, technical, cross-functional programs and working with senior executives
• Experience articulating complex issues to audiences with varying levels of technical expertise
• Experience influencing leaders, breaking down barriers and managing competing priorities
• Strong problem solving and analytical skills
• Excellent communication and interpersonal skills