Director, Claims

Claims Phoenix, Arizona


Description

Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California.

WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to WGAT today!

Job Description Summary

The Director of Claims originates, implements, and leads department objectives that will provide an employee-oriented, customer-centric high performing culture that emphasizes empowerment, quality, productivity and standards, goal attainment, and the recruitment and ongoing development of a superior workforce for all Western Growers Assurance Trust (WGAT) and Pinnacle's Claims Management Inc. (PCMI) members/clients. The incumbent will provide leadership and development to the Claims department and its employees. They will also collaborate with leaders in Installation, Provider Contracting/Maintenance, and Benefits Administration to ensure data integrity and drive financial and operational value across Employee Health Plans. This position reports to the Assistant Vice President, Operations, and has two direct reports; Manager, Claims, and Claims Report Specialist.

Qualifications

  • BS/BA degree in health care administration or related field and seven (7) to ten (10) years' experience in group health benefits administration, specific to claims management in a managed care, self-funded or hospital setting is preferred.
  • Experience leading a claims team at or above the Director level with 50+ direct and/or indirect reports with accountability for setting and meeting key performance factors, mentoring and developing staff.
  • Extensive knowledge of group health care administration and all applicable legal requirements noted within Health Insurance Portability and Accountability Act (HIPAA), Employee Retirement Income Security Act (ERISA), Affordable Care Act (ACA, Patient Protection and Affordable Care Act (PPACA) regulations for health benefit administration operations.
  • Demonstrated strong analytical and process improvement skills with a data-driven approach to problem-solving with strong quantitative skills to spot patterns, trends, and opportunities in data with an emphasis on generation and utilization of data to drive operational and financial performance.
  • Ability to leverage industry best practices, technology innovations, and processes to redesign elements into the claims team's strategic vision to support the organization's continued growth.
  • Solid aptitude at developing departmental budgets and evaluating profit and loss statements to ensure compliance with budget.
  • Demonstrated project management skills to address simultaneous projects, demands, and issues.
  • Excellent proficiency with Microsoft Excel, Word, Outlook, PowerPoint, and Claims benefits systems.
  • Advanced interpersonal, problem-solving, and project/time management skills essential.
  • Strong knowledge of medical coding (ICD-10, HCPCS/CPT, etc.)
  • Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 25% of the time.

Duties And Responsibilities

Department Operations

  • Lead key strategic initiatives and provides leadership for large, complex programs to ensure programs and strategies are implemented and maintained effectively.
  • Develop, implement and monitor successful administrative processes and procedures to maximize employee production and compliance with ERISA, CDI, DOL, and CCSB regulations.
  • Provide leadership and direction to the department, which includes but is not limited to meeting productivity and service goals and identifying skill and resource gaps for current and future workload.
  • Oversee the Member Appeals and Grievance process; complete analytics to identify trends and execute strategies to improve member satisfaction.
  • Manage projects and assign tasks to develop goals and strategies to achieve success in all areas of responsibilities and related activities.
  • Handle complex claims issues escalated by claims agents. Review and advise department staff to troubleshoot and address customer problems.
  • Coordinate external vendor relationships with Utilization Management, Case Management, and clearinghouse vendors to ensure performance within industry standards as required by the benefit plan contracts under WGAT and PCMI.
  • Prepare and submit regulatory and audit reports in a timely manner.
  • Prepare annual departmental budgets and track departmental costs, ensuring these are managed within budget.
  • Act as a technical resource and explain complex laws, regulations, processes, and programs related to areas of responsibility
  • Employ cost containment measures while maintaining quality and efficiency of operations and a productive, healthy work environment.
  • Anticipate expenses and identify potential budgetary concerns to leadership.
  • Develop and maintain metrics and key performance indicators to support a consistent, informative, and timely management reporting package; weekly to AVP, monthly to Senior Leadership, quarterly for the WGAT Board of Trustees.
  • Analyze, track, and trend claims and encounters data; identify any potential service or systems issues; implement interventions and determine the intervention's success.

Process Improvement

  • Identify and implement process improvements to increase operating efficiency
  • Plan, deploy, and lead all lean activities to produce significant cost savings through productivity, quality, waste reduction improvements, and improving business processes.
  • Develop and maintain appropriate and necessary departmental policies, procedures, objectives, and activities relating to improving organizational performance.
  • Oversee and guide the development of comprehensive process improvement plans to be shared with stakeholders.
  • Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution.
  • Manage cross-functional communications across operations stakeholders as new solutions are identified and implemented.
  • Identify and build value roadmaps in collaboration with senior leaders.
  • Conduct data analysis, develop and promote data-driven solutions with the intention of guiding strategies and plans.
  • Provide development opportunities for frontline management, specifically in continuous improvement and leadership skills through various means, including on the job training and influence.

Management & Leadership

  • Develop, manage goals, performance efforts and lead a team of 3A+ self-accountable professionals.
  • Develop a culture of real, personal accountability by modeling the behavior that defines it.
  • Instill a culture of safety and expectation within your respective area/s.
  • Require direct reports to hold themselves accountable to high performance standards and personal conduct in a clear, helpful, straightforward way.
  • Conduct one-on-one conversations with every direct report, quarterly, focused on their 3A+ capabilities, impact, and effort.
  • Ensure a robust mentorship, leadership, management, and technical training programs are in place to continually develop staff.
  • Create a succession and career development plan for all staff members within area of responsibility.
  • Make decisions and choices, impacting staff by selecting and hiring, clarifying roles and objectives, managing performance, correction & discipline, and termination steps outlined in the "Outward Mindset Skills for Leaders" guide.
  • Travel as necessary to make periodic visits to direct and oversee staff in external offices.
  • May be required to attend legal proceedings as a representative on behalf of the organization in conjunction with legal counsel.

Other

  • Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
  • Maintain a valid California License.
  • Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 25% of the time.
  • All other duties as assigned.

 

Physical Demands/Work Environment

The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to travel to both indoor and outdoor areas that can vary in exposure and temperature. The employee is frequently required to operate a motor vehicle, use objects, tools, or controls, and/or required to lift up-to 50lbs. The noise level in the work environment is usually moderate.