CenCal HEALTH
Would you thrive in a highly regarded, mission driven organization that is dedicated to ensuring quality, cost effective care for the underserved? Does your background include broad Claims Operations experience, managing diverse, multi-functional teams in Managed Medi-Cal, Medicaid and/or Managed Care settings? Do you possess exceptional leadership, organization and communication skills? Does the opportunity to work collaboratively with a team that strives for excellence appeal to you? If so, CenCal Health has an exciting opportunity that you may want to consider!
COMPANY OVERVIEW
CenCal Health (formerly The Santa Barbara Regional Health Authority) is the Medi-Cal Managed Care Program for low income residents of Santa Barbara and San Luis Obispo counties. Since its inception in 1983, CenCal Health has, among other things, created access to high quality health care for its members through contracts with local providers and through a primary care provider case management network in addition to Health Education and Disease Management programs and activities. The program that began at CenCal is now acknowledged to be the oldest Medicaid managed care program of its kind in the country and has since become a demonstration program for other counties and states which is a model for Medicaid reform.
CenCal Health is dedicated to the community and local residents. Medi-Cal is CenCal Health’s largest program that is currently serving approximately 178,000 residents in their service areas of Santa Barbara and San Luis Obispo counties. Once members are in the CenCal Health system, they are able to choose (or have assigned) a Primary Care Physician (PCP), which will serve as their “medical home”. Cen Cal Health’s mission is to improve the health and well-being of the communities they serve by providing access to high quality health services, along with member education and outreach. There is a dedicated bilingual, bi-cultural Member Services Department that is able to assist with member questions, appointment scheduling, arranging non-emergency transportation if required, interpreter services at provider offices when needed at no cost and numerous other services.
LOCATION
Santa Barbara is a 2-hour drive north from Los Angeles or a short hop from any corner of the world via the Santa Barbara airport. The city lies between the sleepy Santa Ynez Valley and the Pacific Ocean with a population of 88,410, making it the second largest city in the county after Santa Maria, while the contiguous urban area, which includes the cities of Goleta and Carpinteria, along with the unincorporated regions, has a population of 220,000. The city economy includes a large service sector, education, technology, health care, finance, agriculture, manufacturing and local government. Education in particular is well represented with five institutions of high learning on the south coast. Behind the city is the Los Padres National Forest, which contains several remote wilderness areas. Santa Barbara’s harbor is home to the world-famous Stern’s Wharf and visiting the Wharf and the zoological gardens makes a scenic and educational day trip. From the city, you are just minutes away from the world-famous Santa Barbara wine country. The gorgeous Santa Ynez Valley, with its breathtaking vistas is home to such notable attractions as Solvang and the Chumash Reservation. Santa Barbara’s climate is often described as Mediterranean and it is sometimes referred to as the American Riviera. Its beautiful beaches, majestic mountains, and colorful culture make Santa Barbara a premier place to live and work. Please visit the Santa Barbara Conference & Visitor Council’s website at http://www.santabarbaraca.com for more information.
Job Summary
Reporting to the COO, this position provides strategic and operational direction for the effective management of claims adjudication and claims service.
The Director of Claims is responsible for the overall staffing, planning, fiscal management, administration, and operation of assigned claims functions, programs and activities including, but not limited to Claims Adjudication and Claims Provider Service. The Director will ensure that claims are processed in an efficient and accurate manner by establishing and enforcing department standards within a total quality management approach and in compliance with all applicable state/federal regulations.
The Director provides leadership and guidance for establishing production and work flow systems, setting production and quality standards, approving operating policies, procedures, and claims processing guidelines, coordinating with other departments to ensure that the claims function is achieves business, operations and reporting objectives, and assuring that CenCal Health goals are met
DUTIES AND RESPONSIBILITIES
- Provide leadership to the Claims Department staff and establish objectives which ensure that the department goals and objectives are met
- Supervise directly reporting staff
- Oversee the interpretation and implementation of State and Federal statutes, regulations and mandates (including NCQA, HEDIS, HIPAA, Knox Keene, DHCS, DMHC,) pertinent to claims processing function, while improving claims processes to yield operational efficiencies
- Ensure the timely, accurate configuration of the claims sub-system and maintenance of claims coding databases; implement benefit, provider payment rate updates, and dispute/appeal handling directives from regulatory agencies and Administration
- Create updated Department policies and procedures as necessary
- Ensure the efficient, timely, and accurate adjudication of claims; by maintain an adequate level of trained staff; revising operating workflows, and other necessary changes to effectively implement changing CenCal Health policies and objectives
- Develop, implement, and monitor programs and procedures to assure the efficient and timely submission of accurate encounter data to the State
- Manage the volume and financial impact of pended claims, and status of subsystems maintained by Claims staff
- Ensure staff is advised of all procedural changes in a timely manner, and that such changes are implemented promptly and effectively
- Oversee the claims service functions and claims mailroom to ensure that responses to provider inquiries, disputes or appeals, and internal inquiries are resolved accurately, promptly and with a high level of customer service
- Provide individual and group training for hospitals and other providers on the claims process in coordination with the Provider Services Department
- Implement any policy changes passed by the Board of Directors and/or as directed by Administration which relate to claims processing or service
- Provide monthly Board report and statistics related to claims adjudication or service activities; ensure accuracy of statistical data submitted to Administration
- Collaborate with Compliance, Legal, IT, Provider Services, Health Services, and other necessary departments to ensure that the claims payment system is configured and maintained appropriately to support accurate claims processing and adhere to state and federal regulatory requirements
- Manage vendors used to support claims processing and auditing including, but not limited to, reviewing and modifying contracts, establishing and managing performance expectations, periodically surveying market for alternative vendors and participate in due diligence and annual delegation audits
- Ensure timely recruitment, retention, training and development of qualified claims staff;
- Drive operational innovation and support business expansion and product diversification in support of the CenCal strategic plan
- Determine what environment and culture will create the best workplace experience for department employees
- Ensure that department employees have a clear vision of what each team needs to achieve and that all teams and aligned and committed to department-wide success
- Other duties and projects as assigned
CORE COMPETENCIES
Management Administration Skills:
Manages and/or facilitates employees, budgets and equipment assigned to them, while helping employees maintain a clear picture of their roles and responsibilities to achieve organizational objectives. Helps to develop employee performance by delegating responsibilities and providing accurate feedback and assessments on a timely basis.
Leadership Skills:
Able to assume a role of formal or informal authority as necessary; advocate new ideas, even when risk is involved; delegate responsibility and empower associates to make decisions; capable of providing constructive feedback to others; able to receive constructive feedback from others; makes personal commitment to mentor and grow others.
Strategic Thinking:
Formulates objectives and priorities and implements plans consistent with the long-term interest of the organization in a global environment, Capitalizes on opportunities and manages risks.
Communication Skills-Oral, Listening & Written:
Communicates both verbally & in writing in such a manner that it is easy to understand and interpret what and why information is being communicated. Listens attentively without interrupting and/or being distracted by other things.
Collaboration & Teamwork:
Utilizes communication techniques & methods that generate trust, collaboration, open two-way communication and a supportive work environment. Develops and generates team momentum, enthusiasm, and camaraderie to obtain maximum team performance. Values diverse talents of team members and works to include various points of view in decision-making.
Human Capital Management:
Builds and manages workforce based on organizational goals, budget considerations, and staffing needs. Ensures employees are appropriately recruited, selected, appraised, and rewarded; takes action to address performance problems. Manages a multi-sector workforce and a variety of work situations.
Conflict Management:
Encourages creative tension and differences of opinions. Anticipates and takes steps to prevent counter-productive confrontations. Manages and resolves conflicts and disagreements in a constructive manner.
Decisiveness:
The ability to make difficult decisions in a timely manner.
Walk the Talk:
Do what you say you are going to do. Be accountable for your actions.
World Class Mindset:
Behaves in an honest, fair, and ethical manner. Shows consistency in words and actions. Models high standards of ethics. Punctual, exhibits professional email etiquette. Adhere to company and department standards. Commitment to excellence
EDUCATION AND EXPERIENCE
- Five (5) years of management level experience as a department Director or equivalent in a healthcare environment
- Bachelor’s degree AND four (4) years of recent management experience in medical claims operations OR any equivalent combination of training, education and experience. Health maintenance organization (HMO), Medi-Cal and Medicare claims operations experience is highly desirable
- Knowledge of: managed care contracting methods; health plan core transaction systems; organization and staffing of the medical claims and claims service functions; provider billing and reimbursement methodologies; policies and procedures utilized in medical claims processing; supervisory and staff development techniques; medical economics; fraud, waste and abuse detection and prevention, performance and workflow improvement, NCQA accreditation and HIPAA complaint claim coding guidelines
- Knowledge of Medicaid, Medicare and Commercial health plan operations
- Proficient in Microsoft Office suite and the graphical display of complex financial and operational data
ESSENTIAL FUNCTIONS
- Physical requirements needed to perform the essential functions of this job, with or without accommodation:
- Mobility Requirements: ability to operate a keyboard and sit for long periods; stand, sit, reach, bend, crawl, stoop, lift up to 10 lbs.
- Visual Requirements: ability to read close-up and do close-up work.
- Dexterity Requirements: ability to perform repetitive motion (keyboard); writing (note taking)
- Hearing/Talking Requirements: ability to hear normal speech, hear and talk on the telephone
- Emotional/Psychological Requirements: ability to deal with public contact, in person and Normal office environment. Must be able to sit and work at a computer for long periods of time
- Must be able to travel outside the office and attend meetings during and after regular work hours
- Regular attendance is essential to perform this job
- Must be able to work full time
- Possess a current, valid driver’s license with a clean driving record
The Claims Director will have an opportunity to make a significant contribution to the lives of CenCal’s member population. Share your vision, expertise and skills with a company that is committed to improving the quality and cost of healthcare for the underserved!
For further information, please contact:
Mary Niccum or Susan Pisarik
Executive Search Resource Group, Inc.
Phone: 949.721.8250
Fax: 949.721.8259
Email: exec.search@esrg.com
Disclaimer
The above information on this description has been designed to indicate the general nature and level of work performed by CenCal Health employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.