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PacificSource

Based in Springfield, Oregon, PacificSource is a not-for-profit community health plan that has provided insurance solutions since 1933. Originally established a

Director, Claims and Encounters Operations

Location

Missouri

Posted

73 days ago

Salary

$108.5K - $184.4K / year

Seniority

Lead

Bachelor Degree8 yrs expExperience acceptedEnglish

Job Description

Director, Claims and Encounters Operations

PacificSource

• Lead and manage daily operations for claims processing and encounter submissions across all lines of business. • Execute operational plans that align with organizational strategy, regulatory requirements, and performance expectations. • Ensure consistent achievement of government contractual Service Level Agreements (SLAs) and Commercial Performance Guarantees. • Monitor key performance metrics including productivity, quality, turnaround time, and inventory and implement corrective actions based on trends. • Partner with leadership on capacity planning, staffing models, and workload forecasting. • Design, implement, and refine scalable workflows for claims adjudication and encounter submission. • Identify and implement opportunities to reduce errors, improve first pass resolution rates, and increase operational efficiency. • Collaborate with Payment Integrity and vendor partners to ensure proper claim adjustments and financial accuracy. • Work with IT, Configuration, Compliance, Finance, and Product teams to define business requirements and support system enhancements for claims and encounters processing. • Ensure compliance with CMS, state, and federal regulations, including Medicare Advantage and Medicaid requirements. • Maintain readiness for audits, reviews, and regulatory reporting. • Oversee the development, maintenance, and adherence to policies, procedures, and internal controls related to claims and encounters. • Support continuous improvement initiatives focused on reducing Average Handle Time (AHT), rework, and operational backlog. • Lead, coach, and develop managers and staff through performance management, training, and succession planning. • Manage claims-related vendor relationships to ensure service quality and return on investment. • Participate in cross functional forums to support enterprise initiatives and operational alignment.

Job Requirements

  • Minimum of 8 years of healthcare operations experience, with a strong focus on claims processing and/or encounters.
  • Minimum of 3 years of progressive leadership experience managing teams or managers in a healthcare operations environment.
  • Demonstrated experience in operational improvement, workflow design, and performance management.
  • Experience working with Medicaid, Medicare Advantage, and Commercial lines of business strongly preferred.
  • Experience supporting or operating within a cost containment program preferred.
  • Bachelor’s degree required.
  • Preferred areas of focus: business, finance, healthcare administration, or a related field.
  • Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.
  • Strong knowledge of claims adjudication, encounter submission, and processing systems.
  • Working knowledge of CMS regulations, state Medicaid requirements, and audit readiness practices.
  • Proven ability to lead teams through operational change and performance improvement.
  • Experience using data and metrics to drive accountability and results.

Benefits

  • Flexible telecommute policy
  • medical, vision, and dental insurance
  • incentive program
  • paid time off and holidays
  • 401(k) plan
  • volunteer opportunities
  • tuition reimbursement and training
  • life insurance
  • options such as a flexible spending account

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