Director, HMO Claims Services
Facility: Scripps Health Corp
Location: San Diego, CA
Career Area: Finance
Employment Type: Full Time
Shift: Day
Job ID: 242007201
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Scripps Health Administrative Services supports our five hospital campuses, 31 outpatient centers, clinics, emergency rooms, urgent care sites, along with our 17,000 employees, more than 3,000 affiliated physicians and 2,000 volunteers.
Job Description
This is a full-time leadership position, eligible for Scripps Health annual Management Incentive Compensation Plan. This position is partial remote and located in San Diego and does require residence in San Diego. The weekly schedule will be 2 days in the office and 3 days remote.
Join the Scripps Health team and work alongside passionate caregivers and provide patient-centered healthcare. Receive endless appreciation while you build a rewarding career with one of the most respected healthcare organizations nationwide.
Why join Scripps Health?
AWARD-WINNING WORKPLACE:
- #5 in Fortune Best Workplaces in Health Care 2023
- #78 in 2023 PEOPLE Companies that Care
- #95 in Fortune 100 Best Companies to Work for 2023
- Recognized by Newsweek as one of America’s Greatest Workplaces for Diversity in 2024
- Nearly a quarter of our employees have been with Scripps Health for over 10 years.
The Director of HMO Payment (Claims) Services for Scripps Health Plan, leads claims payment team and ensures accurate and timely payment of provider and institutional claims. Candidate will manage successful Plan and DMHC Audit performance, staff education and training, and manages PDR process. This individual will interface with all MSO and Plan departments to ensure proper workflow and serve as SME for IS implementations and reporting.
(This is not a revenue cycle – claims billing position)
Successful candidate will demonstrate:
- Claims automation optimization.
- Claims recovery.
- Epic/Tapestry expertise including workbench and WebI reporting.
- Reporting and KPI development and management.
- Experience with mailroom.
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Required Education/Experience/Specialized Skills:
- 8 years’ experience in managed care claims, 3 of which in leadership.
- Expertise is California DMHC claims regulations, NCQA regulations and health Plan experience.
- Strong technical aptitude for computer systems and databases.
Preferred Education/Experience/Specialized Skills/Certification: .
- Bachelor’s degree in related field.
- Epic Tapestry experience.
- Strong reporting experience, specifically Epic Workbench and WebI.
- Understanding of institutional and professional claims, implications and codes.
- Experience with DMHC audits, health plan audits, CPT and ENM coding
- Mailroom experience.
In compliance with the California Pay Transparency Act, Scripps Health posts the pay range for all jobs. Please note that actual pay will be determined based on relevant experience and internal equity within the pay range. Please also note this range is applicable for employees who reside in California only. A geographical pay differential may be applied for remote employees who reside out of state. Scripps Health strives to ensure that our employees receive equal pay for equal work in line with our commitment to being an equal opportunity employer.
Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability.
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About Us
At Scripps, we seek dedicated, compassionate people to join our team and make a significant impact on the health of our community and the future of healthcare. Throughout our five hospital campuses, 30 outpatient centers and clinics, and hundreds of affiliated physician offices throughout the region, each member of our team plays a key role in our life-changing and life-saving mission. Scripps Health is the only San Diego-based company to make Fortune magazine’s 100 Best Places to Work. Our people and their commitment to the highest standards of care are what define us.
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