LOCATION: Remote – This is a home based, virtual position that operates on US Eastern Standard time within the hours of 8:30am-5:00pm EST. Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL. Preference will be given to a North Carolina resident. This position may require occasional travel into Vaya’s Asheville NC office.
GENERAL STATEMENT OF JOB
The Vice President of Claims will be responsible for overseeing all aspects of the claims operations, with a specific focus on North Carolina Medicaid. This position will lead a team of claims professionals, develop and implement strategies to optimize claims processing, and ensure compliance with relevant regulations and guidelines. Expertise in North Carolina Medicaid policies and procedures will be critical in driving operational excellence and enhancing the overall claims management function.
ESSENTIAL JOB FUNCTIONS
Strategic Leadership:
- Lead and manage the claims department, providing strategic direction and guidance to achieve departmental goals and objectives.
- Provide strong leadership, setting clear expectations and fostering a positive work environment.
- Develop and maintain strong relationships with key stakeholders, including state Medicaid agencies, providers, and third-party administrators.
Claims Management:
- Develop and implement efficient and effective claims processing workflows, ensuring high accuracy and productivity.
- Stay updated with the latest North Carolina Medicaid regulations, policies, and procedures, and ensure compliance within the claims operations.
- Collaborate with cross-functional teams, including finance, operations, and compliance, to streamline processes and resolve any claims-related issues.
- Oversee the investigation and resolution of complex claims issues, ensuring prompt and fair resolution for all parties involved.
Data Analysis and Reporting:
- Analyze claims data, identify trends, and implement strategies to reduce errors, improve turnaround time, and enhance overall claims performance.
- Establish key performance indicators (KPIs) for claims operations, analyze data to identify trends and areas for improvement
- Prepare and present reports to executive leadership on claims performance, trends and outcomes
KNOWLEDGE, SKILLS, & ABILITIES
- In depth knowledge of federal and state (North Carolina preferred) regulations related to claims processing and claims reimbursement with specific knowledge of Medicaid programs policy and procedure.
- Understanding of both behavioral health and physical health claims processing.
- Understanding end to end claims management process including submission, adjudication payment and resolution
- Strong analytical skills for interpreting claims data, identifying trends to make data driven decisions to improve process
- Ability to identify and manage risks associated with claims operations, ensuring proactive mitigation strategies are in place
- Strong leadership skills that will lead a team towards departmental and organizational goals
- Excellent written and verbal communication skills that can address diverse audiences
- Proficient in analyzing complex issues, identifying root causes and implementing effective solutions
- Able to build and maintain positive relationships with both internal and external stakeholders
- Able to think strategically and align claims operations with the organizational strategic plan and vision
- Sound judgement and ability to make decisions in situations requiring quick and informed decisions
- Ability to manage conflicts effectively within the Claims teams or other internal/external stakeholders
QUALIFICATIONS & EDUCATION REQUIREMENTS
Bachelor’s degree in Finance, Accounting, Computer Information Systems, or Business Administration required; Master’s degree preferred.
- A minimum of 10 years of experience working in Claims with 7 years of experience in a leadership position working within claims management required
- Specific focus on Medicaid, preferably within the state of North Carolina is preferred
PHYSICAL REQUIREMENTS
- Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
- Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
- Mental concentration is required in all aspects of work.
RESIDENCY REQUIREMENT: The person in this position must live in NC, SC, GA, TN, VA, MD, or FL. Preference will be given to a North Carolina resident. This position may require occasional travel into Vaya’s Asheville NC office.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled.
APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
