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The future of payment integrity.
Director of Data Mining Operations, Healthcare Payment Integrity
Location
United States
Posted
105 days ago
Salary
0
Seniority
Lead
Job Description
Director of Data Mining Operations, Healthcare Payment Integrity
Machinify
• Lead and scale a high-performing team responsible for operational execution of data mining and audit-support activities • Ensure operational outputs are accurate, consistent, and actionable • Build, manage, and deliver against annual and ongoing budgets • Monitor operational spend and ensure the organization meets financial targets • Collaborate closely with client-aligned stakeholders and internal cross-functional partners • Continuously improve operational processes and performance through strong metrics discipline
Job Requirements
- Strong communication and executive presence
- Significant experience leading operational data mining, claims analytics, payment integrity, audit operations in a healthcare environment
- Strong people leadership experience
- Ability to scale and mature an execution-oriented team
- Familiarity with healthcare claims data, audit processes, payment integrity concepts, and data mining approaches is strongly preferred
- Experience working in vendor-client delivery models
- Demonstrated success managing budgets, headcount planning, and operational forecasting in a fast-paced, service-oriented environment
Benefits
- Work from anywhere in the US! Machinify is digital-first.
- Top Medical/Dental/Vision offerings
- FSA/HSA
- Tuition reimbursement
- Competitive salary, 401(k) with company match
- Additional health and wellness benefits and perks
- Flexible and trusting environment where you’ll feel empowered to do your best work
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Operations Manager, Member & Provider Services
WellSense Health PlanWellSense Health Plan is a nonprofit health insurance company. As an employer, the company strives to foster a fast-paced, goal-motivated, and supportive culture for its team membe
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Reporting to the Director of Member and Provider Service, the Operations Manager is responsible for providing operational oversight including compliance, program development, evaluation, and performance monitoring. This role assumes management of and accountability for day-to-day service operations and is the subject matter expert for service operations. Key Functions/Responsibilities - Work with Director on development and execution of service strategy - Identify trends, risks, and opportunities to set strategic direction - Identify key strategic considerations for efficient workflows, best practices, and service models - Collaborate with functional leaders to identify initiatives that improve service to members and providers, create efficiencies, and support product growth and health improvement initiatives - Synthesize information into impactful materials and presentations to facilitate recommendations to the COO and Executive Teams - Lead business planning efforts for Member and Provider Service - Effectively work in a matrix environment to accomplish work across multiple teams in the health plan and health system - Lead meetings, put content into framework, organize people, and drive implementation - Understand and visualize data, make data-driven decisions, and create reporting - Develop, implement, and enhance processes to drive overall performance of service initiatives - Lead implementation projects assigned in accordance with priority - Develop methodologies and infrastructure to measure the impact of executed initiatives - Represent Member and Provider Service as the subject matter expert on corporate initiatives - Make recommendations related to member and provider service impact and operations - Lead implementation of any resulting work, internal project teams, coordinates communication, training, documentation, and reporting - Identify, communicate, and escalate issues to the Director of Member and Provider Service on a timely basis - Independently problem-solve programmatic issues and implement appropriate solutions - Responsible for ensuring compliance with contractual and regulatory requirements - Effectively document the components of the programs necessary for compliance with regulatory standards and submission to external agencies - Represent Member and Provider Service in meetings with external auditors and regulators - Coordinate and track the completion of regulatory training for all Member and Provider Service staff and responsible vendors - Develop and oversee the production of regulatory reports and standard KPI reports - Implement operational enhancements in partnership with Service leadership - Accountable for timely notification to the Director and Service Manager if operational performance falls below expectations - Collaborate with Service leadership, CX Analyst, and vendors to identify opportunities for improvement Supervision Exercised No direct reports; manages projects in a matrixed environment. Supervision Received Weekly supervision with Director of Member and Provider Service. 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