Claims Director of Provider Disputes at Kforce Inc in Montebello, California

Job Description:

RESPONSIBILITIES:

Kforce has a client in Montebello, CA that is seeking a Claims Director of Provider Disputes.

Summary:
The Claims Director of Provider Disputes and Resolution has overall responsibility and accountability for all aspects of the claims operation for all Provider Disputes, provider projects, as well as provider refund recoveries. Within this role, the Director will ensure to meet regulatory compliance as well as company objectives as they relate to the resolution of the provider issue. The Director is responsible for leading and supporting each unit while being accountable for performance management, quality improvements and operational accuracy. The Director will leverage experience and integrate various components of cross-functional business
decisions to continuously improve claims' processes and procedures.

Responsibilities:

• Participate in various forums, company initiatives, and other internal/external workgroups to support Claims integrity. Directs all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports


• Oversees claim disputes from Providers as it relates to underpayment, overpayments, or no payment


• Oversees provider projects as it relates to underpayments, overpayments, or no payment


• Oversees refund recoveries, including requesting refunds as well as posting of the refunds to the related claim


• Provides guidance to ensure that Claims Integrity efforts are performed with the highest and most current rules, regulation, policies, business rules and industry standards


• Develops, manages, and sustains relationship with managed care service providers


• Collaborates with various business unit's operational management in identifying, prioritizing, and resolving the issues impacting claims quality

REQUIREMENTS:

• Strong verbal and written communication skills


• Strong leadership skills, emphasizing interpersonal and functional abilities


• Through knowledge of Managed Care regulations and compliance guidelines


• Ability to audit and conduct performance evaluations of department and staff


• Ability to follow and communicate complex instructions and directions


• Strong computer skills, proficiency in Microsoft Office programs-MS Word, Excel, and Power Point


• Knowledge of healthcare reimbursement and billing procedures, CPT and ICD-10 coding, and medical terminology


• Ability to plan, prioritize and schedule multiple work assignments; High degree of organization and time management skills

The pay range is the lowest to highest compensation we reasonably in good faith believe we would pay at posting for this role. We may ultimately pay more or less than this range. Employee pay is based on factors like relevant education, qualifications, certifications, experience, skills, seniority, location, performance, union contract and business needs. This range may be modified in the future.

We offer comprehensive benefits including medical/dental/vision insurance, HSA, FSA, 401(k), and life, disability & ADD insurance to eligible employees. Salaried personnel receive paid time off. Hourly employees are not eligible for paid time off unless required by law. Hourly employees on a Service Contract Act project are eligible for paid sick leave.

Note: Pay is not considered compensation until it is earned, vested and determinable. The amount and availability of any compensation remains in Kforce's sole discretion unless
and until paid and may be modified in its discretion consistent with the law.

This job is not eligible for bonuses, incentives or commissions.

Kforce is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.

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