Director, HMO Claims Services
Job Description
This is a full-time leadership position, eligible for Scripps Health annual Management Incentive Compensation Plan. This position is partial remote and located in San Diego and does require residence in San Diego. The weekly schedule will be 2 days in the office and 3 days remote.
Join the Scripps Health team and work alongside passionate caregivers and provide patient-centered healthcare. Receive endless appreciation while you build a rewarding career with one of the most respected healthcare organizations nationwide.
Why join Scripps Health?
AWARD-WINNING WORKPLACE:
- #5 in Fortune Best Workplaces in Health Care 2023
- #78 in 2023 PEOPLE Companies that Care
- #95 in Fortune 100 Best Companies to Work for 2023
- Recognized by Newsweek as one of America's Greatest Workplaces for Diversity in 2024
- Nearly a quarter of our employees have been with Scripps Health for over 10 years.
The Director of HMO Payment (Claims) Services for Scripps Health Plan, leads claims payment team and ensures accurate and timely payment of provider and institutional claims. Candidate will manage successful Plan and DMHC Audit performance, staff education and training, and manages PDR process. This individual will interface with all MSO and Plan departments to ensure proper workflow and serve as SME for IS implementations and reporting.
(This is not a revenue cycle - claims billing position)
Successful candidate will demonstrate:
- Claims automation optimization.
- Claims recovery.
- Epic/Tapestry expertise including workbench and WebI reporting.
- Reporting and KPI development and management.
- Experience with mailroom.
#LI-JS1
Required Education/Experience/Specialized Skills:
- Bachelor's Degree plus 5 years' experience in managed care claims leadership.
- Expertise is California DMHC claims regulations, NCQA regulations and health Plan experience.
- Strong technical aptitude for computer systems and databases.
Preferred Education/Experience/Specialized Skills/Certification:
- Master's degree is related field.
- Epic Tapestry experience.
- Strong reporting experience, specifically Epic Workbench and WebI.
- Understanding of institutional and professional claims, implications and codes.
- Experience with DMHC audits, health plan audits, CPT and ENM coding
- Mailroom experience.
Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, age, status as a protected veteran, among other things, or status as a qualified individual with disability.
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