S ummary: Position is responsible for overall strategy and effectiveness of Claims Operations. Position is responsible for oversight of claims adjudication and regulatory reporting functions including all associated processes, reporting of key performance indicators and definition of operational efficiencies. This position is also responsible for the timely processing and accuracy of claims and day to day interactions with any vendor partners that have direct impact to claims processing or pricing rules. Identifies and implements new processes, vendors, practices to improve efficiency within the department. Responsible for hiring, orienting, training, assigning, coaching, mentoring, counseling and performance oversight for the Claims staff. Essential Duties and Responsibilities: Establishes consistent standards, practices, and processes focused on timely and accurate adjudication of claims With limited direction, translates regulatory and business requirements to technical specifications for claims configuration including process documentation Works closely with stakeholders including clinical, operations and finance teams during the development of key workflows to ensure alignment of overall objectives and key requirements Shall perform and oversee user acceptance testing for any impacted changes to claims processing Demonstrate expertise in interpretation and serve as Subject Matter Expert (SME) in the development, validation and submission of all Claims related regulatory reporting. Includes but is not limited to reports required by CMS, TDI, and Texas APCD. Demonstrate expertise and serve as SME on data elements/language on EOPs and EOBs. Provide escalation support for business or revenue impacting performance or delivery issues within core business systems as assigned through the creation of remediation plans; Track and support ongoing management of outstanding escalations to final resolution Develop staffing model to support Claims budget process Develop and implement a comprehensive Claims Quality program to measure financial and clerical accuracy. Identify trends, develop and execute corrective action plans. Consults and coordinates with various internal departments, external resources, business partners, and government agencies as appropriate Serves as point of contact in researching and presenting Claim data in all legal issues Serves as company representative in Independent Dispute Resolution (IDR) cases Monitors claim inventory levels and implements control processes to always ensure maximum production Ability to predict and forecast changes in business operational activities that may result in changes in staff workload Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff Monitors system and business functionality and performance Utilizes a detailed understanding of insurance, processes, and business systems to drive the research and analysis of the defined problem, design the recommended solution, and implement the solution, while addressing associated change management. Develops and maintains departmental policies and procedures and desktop procedures according to current business needs as well as industry and regulatory requirements Documents operational and technical workflows as appropriate Education/ Experience: Bachelor’s Degree or at least 10 years commensurate experience is required; Bachelor’s Degree in business or health care related field preferred Licenses/Certification: None required; CPC preferred Ability to work from home with appropriate internet access and a quiet and private workspace. Minimum 7 years of claims and health care administration and/or managed care management experience Strong knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, DSNP, etc…) Extensive knowledge of claims policies and procedures including regulatory requirements and industry standards from AMA, CMS and CCI edits. Strong computer skills, specifically with Microsoft Office and Windows. A desire to serve others while being empathetic with the drive to go above and beyond to help resolve questions at the first point of contact. Must have a strong work ethic and a sense of responsibility to other team members and external stakeholders to meet all needs represented by a robust sense of accountability Adaptable and a quick learner, willing to change to meet shifting customer and business needs. Exceptional time management skill. Ability to meet tight turnaround times with quality results. Excellent verbal and written communication skills Extremely organized and detail oriented. The ability to develop effective working relationships, and work collaboratively with all levels of staff, vendors, and partners. Ability to work independently on a variety of projects in a high volume, fast paced, and sometimes nebulous environment required Demonstrated pattern of growth in ability to lead, motivate, develop and mentor others Solid business acumen, decision making, research and analytical skills About Apex Health Solutions Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.