EHP Claims Appeal Director - PHMI EE Benefits in Ontario, CA at Prime Healthcare

Date Posted: 4/3/2021

Job Snapshot

Job Description

Responsibilities The EHP Claims Appeal Director is responsible for providing strategic leadership and development of the EHP Claims Department and its employees, as well as collaborate with Provider Affiliation and Member Relations, Contracting, and Benefits Administration to ensure data integrity and to drive financial and operational value across Employee Health Plans and maximize benefit coverage while containing cost. Through inter-professional collaboration, The Director analyzes outcomes for the self-insured Employee Health Plans and develops strategies to improve workflows and accomplish organizational goals and objectives. Ensures that TPA and Health Plans are notified in a timely fashion of any changes in process or procedures which would impact their functions.



Required qualifications:

    Bachelor’s Degree in Business Management, Healthcare Administration, or other relevant fields.A minimum of seven (7) years of prior work experience in Claims Operations and Health Plan Strategy, in a Managed Care, Self-Funded or hospital setting is required.Analytical skills with emphasis on generation and utilization of data to drive operational and financial performance. Ability to work in a complex, rapidly evolving environment with multiple internal and external entities and boundaries.Strong interpersonal skills, problem solving and project/time management essential.Ability to develop presentations to all levels using Microsoft Office applications.Strong knowledge of medical coding (ICD-10, HCPCs/CPT, etc.)
Preferred qualifications:

    Master’s Degree in Business Management, Healthcare Administration, or other relevant fields. Familiarity with multiple Business Intelligence software systems and daily usage of at least one.Certified Professional Coding Certification, AIC, ARM, or equivalent.Hands on experience with TPA
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law: