Director of Health Plan Operations

The Director of Health Plan Operations oversees claims processing, risk adjustment and A/R management of capitation revenue from Medicare and Medicaid. Directs and coordinates implementation, design, and maintenance of fiscal insurance information systems and ensures they align with government reporting requirements.

Essential Responsibilities:

• Develops revenue cycle metrics/key performance indicators and reporting systems to monitor risk adjustment cycle performance.
• Provides day to day oversight for Hierarchical Condition Category (HCC) risk adjustment and reporting measures operations.
• Leads / Directs claims analysis to explain variance, identify trends, and monitor Fraud, Waste, and Abuse (FWA)
• Develops new reporting, measures and metrics to support Medical Cost Management Committee and as needed.
• Ensures encounter data is being accurately documented and relevant procedural codes and all diagnosis codes are captured by team to ensure no revenue loss.
• Collaborates with physicians, coders, staff and a variety of internal and external personnel on a wide scope of Risk Adjustment education efforts.
• Establishes audits for clinical encounters and claims and audits for completeness, accuracy of information and compliance with organizational policies, standards and procedures.
• Key liaison with claims system/practice management system vendor.
• Leads claims configuration, auditing and pricing/benefits set up within the claims payment system ensuring accurate reflection of provider contracts with claims payment.
• Ensures appropriate system testing, procedure/control development and ongoing improvements.
• Directs and oversees the evaluation and analysis of upcoming implementations to ensure successful and smooth transition into claims systems and processes.
• Ensures compliance with federal and state regulations.
• Directs the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with the contracted fee schedules and covered benefits.
• Lead others to solve issues and provide direct oversight of the more complicated or escalated issues around claims performance and reduce rework.
• Identifies and implements opportunities to automate processes to increase effectiveness and efficiency.
• Liaison with IT to create seamless ability for the business to leverage the services & expertise of the IT organization to obtain the business automation solutions necessary to ensure regulatory and compliance goals are met.
• Recruits, develops, mentors and motivates staff.  Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
• Performs other duties as assigned.

Job Specification:

• Bachelor’s degree in related field. Master’s degree preferred.
• Experience working with CMS, risk adjustment, health insurers and medical provider coding.
• Experience working with a Medicare Advantage organization.
• Experience with health insurance claims
• Minimum of 5 years of Risk Adjustment Data Validation process/audit experience preferred.
• Minimum of 5 years leading teams preferred.
• Excellent problem-solving, analytical and time management skills.
• Ability to effectively use technology in support of management and financial operations.
• Ability to effectively lead a team and liaise/collaborate with other departments.
• Covid vaccine required.

EEO Statement

Element Care is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.

Element Care is committed to valuing diversity and contributing to an inclusive working environment.