Director, Claims

Reporting to the COO, the Director of Claims provides strategic management and collaboratively leading the ongoing operations of the Claims Department at SFHP, ensuring financial integrity and exemplary service and achieving established goals and objectives. You will maintain internal communications to promote SFHP's mission, support SFHP's primary purpose, and work to maintain a team environment where staff can be effective, satisfied and provide quality service to all customers, internal and external.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $150,000 to $175,000 per year

WHAT YOU WILL DO:

• Lead strategic planning and management of Claims and Quality Assurance. Manage, coach, and inform the department managers and supervisors of information and tools needed to be successful.
• Lead the development of achievable, relevant departmental goals, and metrics, and ensure they are used to motivate staff.
• Ensure internal audit by QA of key operational processes in Claims including end-to-end claims processing.
• Chair monthly QA results review meetings, capacity planning, recommending, and implementing standards for and making improvements on Claims and QA operations.
• Preserve integrity of audit findings to ensure KPI measures on claims quality are accurate and champion compliance with all SFHP guidelines and regulatory standards.
• Monitor department metrics, trends, and takes action to support goal achievement. Provide leadership, facilitate meetings, and partner with stakeholders in the resolution of issues.
• Determine staffing needs, set short-term goals, and resolve staffing issues.
• Direct the improvement of business processes and accuracy of documentation of policies and procedures.
• Drive opportunities for automating functions and champion excellent customer service throughout the organization.
• Improve inter-departmental collaboration, communication, and teamwork.
• Take on escalated issues with delegated groups or providers, and members.
• Oversee Key Performance Indicators (KPIs) for the department and support the team in achieving them.
• Manage resource capacity and team allocation to service requests, projects, organizational work groups, and ad hoc assignments.
• Communicate with all levels of staff to facilitate efficient issue identification and resolution.
• Provide leadership and business expertise on assigned projects and processes.
• Ensure the department staff is informed of organization-wide information and decisions.
• Work with direct reports and teams to identify critical issues and trends, make recommendations, and provide information and recommendations to executive management; alert executive management to issues that affect the organization.
• Prepare budget, monitor, and manage expenses for the Claims Department.
• Partner with Business Solutions and ITS to identify critical issues and trends, make recommendations, and provide information and recommendations to executive management.
• Collaborate with EPMO to ensure that work and projects are completed, cost-effective manner, and take corrective actions.
• Ensure the appropriate reporting on a monthly, quarterly, and annual basis; assist with company financial planning and budget management responsibilities.
• Represent Claims with all partners.
• Oversee department participation in all regulatory and financial audits, including resolution of audit findings.
• Participate and engage with peers at Local Health Plans of California (LHPC) to promote knowledge sharing and identify opportunities to lead best practices at SFHP.
• Provide updates to leadership and determine when escalations are necessary.

WHAT YOU WILL BRING:

• A bachelor's degree in health care administration, business, or a related field or equivalent experience.
• Ten years of claims operations experience in a managed care environment, which includes experience with the Medicare, Medi-Cal, and managed care regulations.
• Six years of management-level experience with demonstrated success in managing and developing staff, promoting teamwork and encouraging innovation.
• Experience with healthcare regulatory processes and compliance audits.
• Experience in process or continuous improvement and performance management.

WHAT WE OFFER:

• Health Benefits
  
  
  
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
  
  
  
  
• Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

ABOUT SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

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