• Director, Systems Management

    Job Locations US-VA-Glen Allen
    Job ID
    2018-5093
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    The Director, Systems Management will be a key member of the Claims department’s leadership team and will play a critical role in the support to the Operations unit by ensuring claim systems are optimized, for efficiency, properly aligned with Program and Regulatory requirements and reporting is in place for accurate and timely claims payment.  The Director will collaborate with other leaders both internal and external to Claims to define strategy for success that prevent negative impact to claim payment.  This individual will identify functionality gaps and automate manual adjudication and processes.  He/she will work with various levels of the staff to close knowledge gaps and ensure proper project planning and deliverables are met in a timely fashion.

     

    In addition, the Director will provide oversight for all Claim Systems Management related task to include, but not limited to requirements gathering for new programs, system upgrades, system development, reprocessing, impact analysis, reporting, and resolution of incorrect payment and all configuration and ongoing system maintenance for all lines of business on our legacy system.

     

    The Director of Systems Management will define strategies that ensure high quality solutions and facilitate the breaking through of barriers.

    Responsibilities

    • Collaborate with other Operational Directors to ensure Claims Systems are optimized to achieve high auto-adjudication rates, accurate and timely claim payment
    • Work across department to define and document business requirements for Claims
    • Identify opportunities to incorporate new technology to enhance existing processes and work flows
    • Ensure program benefit grids, training material, SOP’s are kept current and custom configuration is documented
    • Act as a Claims lead in Compliance related audits to provide guidance and expertise to ensure programs and strategies are implemented and maintained effectively
    • Establish appropriate priorities and mange resource allocation across lines of business
    • Provide leadership on best practices in assuring quality configuration, reporting, testing and all data that impact payment
    • Help facilitate the identification of project scope, timelines, resources, resource gaps and project risks, success measures and ensure deadlines are met.
    • Provide direction on troubleshooting complex system issues and develop solutions
    • Ensure identified enhancements to system platform and processes are implemented and monitored for success and continuous improvement opportunities
    • Establish meaningful and measureable goals that align with corporate vision
    • Establish metrics for all pertinent functions that measure both individual and team performance and departmental standards
    • Demonstrate successful leadership in staffing, developing, motivating, training and directing a highly effective team, which includes mentoring and providing guidance to ensure continual growth of the management team

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • Bachelor’s degree in Business Administration, Information Systems, Health Care or other related fields
    • Master’s degree in Business Administration, Information Systems, Health Care or other related fields preferred

     
    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Proven knowledge of Managed Medicaid, Medicare claims payment methodologies in a TPA, HMO, Healthcare Exchange or hospital setting
    • Knowledge of CPT, ICD 10 and HCPS coding system
    • Proficient experience writing TSQL or SQL queries
    • Extensive experience in systems /application management
    • Cognizant /QXNT Claims Platform experience is a plus
    • Ability to comprehend and interpret provider contracts, regulatory payment methodologies and benefits outlined in our program contracts
    • Ability to manage multiple priorities, adapt to changing conditions and thrive in a fast pace environment
    • Proven analytical skills, project management and strategic planning with an emphasis on process improvement
    • Proficient knowledge of Microsoft Office Suite
    • Ability to provide strong leadership in a team environment and excellent time management
    • Excellent communication skills, both oral and written
    • Handles difficult situations diplomatically
    • Ability to build strong relationships within and outside the health plan

     
    WORK BACKGROUND/EXPERIENCE

    • 7+ years implementing or configuring health claims systems
    • 5+ working in healthcare or with health claim related data
    • 7+ years management experience in information systems, application support or related fields; managing analytical staff
    • 7+ years gathering business requirements, managing projects and process improvements


    PHYSICAL REQUIREMENTS

    • Physical health sufficient to meet the ergonomic standards and demands of the position

     

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

     

    Our mission is to inspire healthy living within the communities we serve!

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