Director of Claims & Cost Containment
Alpine Solutions Group - Paoli, PA
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Our client, a fast-growing company who specializes in self-funded employe benefits firm is seeking a Director of Claims & Cost Containment. This position will work a hybrid schedule and will act as a strategic leader who is responsible for overseeing and optimizing our insurance claims management processes/cost containment strategies. This individual will be a team of one to begin with and report into the VP of Stop Loss. You will help develop innovative solutions to enhance operational efficiencies and ensure compliance with regulatory standards. The ideal candidate will possess extensive experience in insurance claims management, a strong grasp of cost containment techniques, and a proven track record of leadership in a dynamic organizational setting. Moreover, the company is currently doing the post care prepayment piece of cost containment (i.e. reducing bills that have already happened, assess billing errors, assess charges, etc). We are looking for someone who can establish process to help monitor incoming claims, negotiate the claims, over the vendor partners, and perform bill reduction strategies.Claims Analysis & ReviewEnsure financial accuracy of claims processing of all TPA'sResearch & apply appropriate claims processing rules & regulatory policiesCreate reimbursement policies when neededReview of benefit plansResponsible for reporting month & quarterly findingsComplete specialized focused auditsMonitor precert and CM activity, performing precert audits pre/post appointmentPerform Quarterly Claim Audits of specific category as well as TPA claim processing audits. Contract Negotiations Interpret Provider Contracts for proper payments to ensure claims systems are paying appropriatelyNegotiate with providers for when applicableAnalyze financial impact of contracts & termsBuild relationships & be the point of contact
Created: 2024-09-16