DELTA HEALTH SYSTEMS MCC

Role Description The Director of Operations is responsible for leading operational teams and ensuring efficient service delivery across multiple departments, including claims, customer service, implementations, and operational support functions. This position reports to the Vice President of Operations and partners closely with leadership to support strategic initiatives, process improvements, and organizational goals. Essential Duties and Responsibilities - Leading and supporting operational and implementation teams - Managing workflow, productivity, and service delivery standards - Coaching, mentoring, and developing staff and leaders - Conducting performance evaluations and addressing performance concerns as appropriate - Collaborating with internal departments and external partners to resolve operational issues - Identifying process improvements and operational efficiencies - Monitoring adherence to company policies, procedures, and applicable Collective Bargaining Agreements - Participating in hiring, training, and workforce planning initiatives - Preparing operational updates, reports, and recommendations for executive leadership - Representing DHS in meetings with customers, vendors, and business partners - Supporting a positive, collaborative, and service-focused work environment - Performing other duties as assigned Qualifications - Bachelor’s degree in business, healthcare administration, or a related field, or equivalent combination of education and experience - Minimum of five (5) years of management experience within a TPA, health plan, or similar operational environment - Demonstrated experience leading teams in a fast-paced, service-oriented organization - Strong communication, problem-solving, and organizational skills - Ability to manage multiple priorities and projects simultaneously - Proficiency in Microsoft Office Suite - Ability to travel occasionally to company offices and client locations Preferred Knowledge and Skills - Experience analyzing operational, financial, and utilization data - Experience implementing operational process improvements - Ability to build effective working relationships across departments and with clients - Strong leadership, collaboration, and conflict resolution skills Work Location This position is based in California and may require periodic travel between DHS office locations and customer sites. Equal Employment Opportunity Statement Delta Health Systems is an Equal Opportunity Employer and is committed to providing equal employment opportunities to all employees and applicants without regard to race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, military or veteran status, or any other protected status under applicable federal, state, or local law. Reasonable Accommodation Delta Health Systems complies with the Americans with Disabilities Act (ADA) and the California Fair Employment and Housing Act (FEHA). Reasonable accommodations will be provided to qualified applicants and employees with disabilities upon request. Internal Applicants Current employees who meet the minimum qualifications for the position are encouraged to apply in accordance with applicable company policies and any governing Collective Bargaining Agreement provisions.

Role Description Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines. - Process claim payment thoroughly, attend all training, and refresher courses. - Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes. - Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing. - Establish and maintain COB files, determine other coverage according to regulatory and plan requirements. - Apply COB payments for final claim payment. - Research and determine proper CPT procedure and ICD-10 Diagnosis Codes. - Research and respond to written correspondence from participants, providers, and local unions/employers. - Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines. - Work effectively to achieve at a minimum production, quality, and accuracy standards. - Display maturity, composure and ability to operate under stress conditions. - Follow department policy and procedures distributed. - Attend mandatory department meetings as scheduled. - Assist other department areas as required dependent on workload and inventory needs. - Excellent organization and assignment management skills. - Clear communication with internal and external customers. - Ability to navigate in external network pricing platforms. - Ability to prioritize workload and adhere to network administrative agreements. - Maintain professionalism at all times. - Perform other duties as assigned. Qualifications - High school diploma or equivalent. Satisfactory completion of medical terminology course may substitute for six (6) months of equivalent experience. - Eighteen (18) months experience as a Claims Processor or similar function. - Must have a broad knowledge of medical terminology. - Must possess excellent written and oral communication skills. - Must possess good judgment skills and ability to interpret Department guidelines and contractual benefits. - Working knowledge of DHPR and CMS rules for Claim Submission, Claim Payment, Eligibility, Coordination of Benefits Primary / Secondary. - Experience with Claims and Enrollment systems; COB validation; Understanding of primary secondary coverage rules. - Must be proficient in Excel.

Role Description - Audits work of self-funded Claims and Customer Service department for accuracy according to established procedure guidelines. - Reviews and identifies technical and system quality issues for all aspects of claim processing, corr/recon, and customer service. - Documents, maintains and reports audit statistics. - Accurately interprets claim policy, procedures and standard group benefit provisions. - Provides feedback to management and reviewed employees regarding quality of work. - Maintains confidentiality of employee audits. - Adheres to company rules and regulations. - Maintains a professional relationship and interacts with peers, subordinates, superiors in an efficient and productive manner. - Performs other duties as assigned. Qualifications - One year certificate from college or technical school; or one to three years related experience; and/or equivalent combination of education/experience. - Successful candidate will have medical, dental and hospital claims processing experience. - Strong understanding of computerized claims payment systems, preferably at Delta Health Systems. - Excellent organizational skills. - Thorough understanding of technical claims issues and system edits. - Working knowledge of Microsoft Word and Excel. - Exceptional analytical skills. Company Description Delta Health Systems is an equal-opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Job DetailsJob Location: DHS Remote - Stockton, CA 95219Position Type: Full TimeSalary Range: $22.36 - $22.36 HourlyJob Category: Customer Service Evaluate claims and determine payment or denial according to plan provisions, medical policy, and guidelines. Process claim payment thoroughly, attend all training, and refresher courses. Maintain clear claim notes, benefit quote documentation, thoroughly review patient and family notes. Maintain multiple network access for pricing and authorization to avoid inactivity and disruption for processing. Establish and maintain COB files, determine other coverage according to regulatory and plan requirements. Applies COB payments for final claim payment. Research and determine proper CPT procedure and ICD-10 Diagnosis Codes. Research and respond to written correspondence from participants, providers, and local unions/employers. Transfer claims to Benefit Review for processing instructions and or other departments according to guidelines. Work effectively to achieve at a minimum production, quality, and accuracy standards. Display maturity, composure and ability to operate under stress conditions. Follow department policy and procedures distributed. Attend mandatory department meetings as scheduled. Assist other department areas as required dependent on workload and inventory needs. Excellent organization and assignment management skills. Clear communication with internal and external customers. Ability to Navigate in external network pricing platforms. Ability to prioritize workload and adhere to network administrative agreements. Maintains professionalism at all times. Perform other duties as assigned. QualificationsEducation High school diploma or equivalent. Satisfactory completion of medical terminology course may substitute for six (6) months of equivalent experience. Experience Eighteen (18) months experience as a Claims Processor or similar function. Must have a broad knowledge of medical terminology and must possess excellent written and oral communication skills. Must possess good judgment skills and ability to interpret Department guidelines and contractual benefits. Working knowledge of DHPR and CMS rules for Claim Submission Claim Payment Eligibility Coordination of Benefits Primary / Secondary. Experience with Claims and Enrollment systems; COB validation; Understanding of primary secondary coverage rules. Must be proficient in excel.

Role Description To assist the Account Executive/Account Managers and their assigned clients by performing the following duties and responsibilities. The Client Services Coordinator may communicate directly with clients and brokers with the understanding the assigned Account Executive/Account Manager is copied on all correspondence and/or responsible for reviewing and approving any correspondence distributed. Responsibilities - Collaborates with Account Managers & Account Executives in the development and execution of client/broker needs. - Responsible for client/broker weekly, end of month, and ad-hoc reporting. - Handles phone & email inquiries from clients/brokers. - Gathers information necessary to calculate stats for various performance standards, negotiation logs, subrogation reports, and other custom reports the client/broker requires. - Responsible for providing quarterly and annual reports to Account Manager for client/broker distribution. - Coordinates with Account Manager to maintain positive relationships with clients/brokers. - Establishes and maintains effective customer relationships with key decision makers and stakeholders, including consultants and brokers. - Ensures that reporting data is current, accurate and completed timely. - Handles reinsurance for renewals; pulls claims data, census, enrollment, and pended claim reports as needed. - Completes administrative service agreements, addendums, and special requests. - Responsible for maintaining master documents for report schedules, quarterly/annual meetings and other master lists/trackers as created and implemented by VP of Client Services. - Responsible for uploading/revising information on our website concerning client updates. - Handles faxing, filing, scanning, shredding, and uploading information. - Consistently supports compliance by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Delta Health Systems policies and procedures. Qualifications - 1-3 years experience in coordinator or administrative role, and/or benefit analyst role. - Knowledge of and experience with employee health benefits. - Strong computer and analytic skills, including experience creating client presentations using Microsoft Office programs. - Excellent verbal and written communication skills. - Expertise in handling difficult client issues related to health plan services, policies and procedures. - Knowledge of self-funding preferred.