Claims Configuration Jobs in Utah (NOW HIRING)

The Director of Configuration, Benefit Administration is responsible for design, implementation, and deployment of benefit configuration structure in order to support product and regulatory needs. This role implements the configuration structure within Healthfirst’s technology platforms to administer benefits taking in coordination with Provider Contracting, Claims Operations, Provider Data Management, Clinical Operations, Payment Integrity, and Information Technology. The Director leads forums and meetings with leadership from across the enterprise to develop effective and efficient benefit configuration solutions to achieve business needs and objectives and maintain alignment with claims payment. The Director analyzes complex configuration defects and recommends strategies for successful and timely remediation. The Director leads a team of managers and analysts to ensure accurate, complete, and timely configuration benefit structure and maintenance of existing structure. The Director oversees team performance, configuration production, and quality metrics to ensure that project and department goals are met. The Director also collaborates across other configuration teams to ensure all required configuration aspects are accounted for in planning and implementation of benefit administration configuration structure. This role is critical to the success and growth of Healthfirst membership through product evolution and adherence to regulatory compliance. The objective of this role is to ensure that the benefit structure implementation delivers the intended experience through claim adjudication, including benefits, authorizations, reference data, claims editing, regulatory requirements, payment policies, and overall claim system functionality. The Director serves as the authoritative source for benefit design, product implementation, and regulatory rule adherence within benefit and product. Recognized as an influential leader, the individual at this level functions as a cultural ambassador and strategy driver for Healthfirst. He/she promotes and reinforces behavior that is consistent with Healthfirst’s desired culture and fulfills his/her role in aligning Healthfirst’s strategic initiatives with desired organizational outcomes.

This position requires three days per week in office (Tuesday/Wednesday/Thursday) at 100 Church Street, NYC.

• Develop and implement comprehensive operational strategies aimed at improving efficiency, productivity, and quality.
• Lead initiatives to identify inefficiencies in current processes and procedures, recommending and implementing solutions to optimize workflows.
• Identify opportunities for cost reduction and resource optimization while maintaining or improving service delivery and quality.
• Work closely with department heads, project managers, and other stakeholders to align operational goals with organizational objectives.
• Facilitate collaboration to drive consistent improvement across the organization.
• Support change management efforts related to operational improvement initiatives, ensuring successful implementation and adoption of new processes and technologies.
• Identify potential operational risks and develop mitigation strategies to minimize disruptions and ensure smooth operations.
• Drive flexible, repeatable and scalable benefit configuration design and implementation processes with industry best practices.
• Engage directly with other operational teams and leaders to provide input on the scope, approach, and timing of configuration work.
• Assess upstream and downstream impact of configuration and policy changes to proactively identify and mitigate risk.
• Manage interdependencies across other configuration units and business areas to ensure delivery timelines and project deadlines are met.
• Identify and resolve inconsistencies between system configurations, regulation, contracts, and policies.
• Maintain effective and consistent configuration testing protocols and quality controls.
• Manage and monitor team performance, production and quality.
• Establish structure for ongoing education, training and knowledge share across team.
• Prepare and present updates to the business and senior executives on benefit configuration strategies, activities, and metrics.
• Lead and support company-wide initiatives.
• Work with internal and external parties to ensure benefit administration logic and business rules are well understood and administered appropriately.
• Actively support all compliance and regulatory requirements with appropriate policies, processes, reports, and audit support.
• Additional duties as assigned.

• Bachelor’s Degree from an accredited institution or equivalent work experience.
• HS Diploma or GED from an accredited institution.
• Proven ability to develop strong interpersonal relationships, as a leader and team member with experience communicating and influencing impact and progress to senior leadership level.
• Successful track record developing creative, workable strategies and tactics to accomplish division, corporate and plan goals.

• Master’s degree or MBA from an accredited institution.
• HealthEdge configuration and integration experience.
• Proven experience in health insurance focused on claim configuration and reimbursement processes.
• Proficiency in provider contract reimbursement terms and code sets (HCPCS, ICD10, DRGs, CPT, etc.) and claims processing practices.
• Knowledge of medical claims and adjudication procedures, including the application of reimbursement and medical policy guidelines and contract pricing.
• Knowledge of benefit administration and/or claim payment methodologies and regulatory frameworks governing health plan reimbursement methods in Medicare, Medicaid and commercial insurance markets.
• Experience leading complex, technical, cross‑functional programs and working with senior executives.
• Experience articulating complex issues to audiences with varying levels of technical expertise.
• Experience influencing leaders, breaking down barriers and managing competing priorities.
• Strong problem‑solving and analytical skills.

N/A

N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disabilities Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying.

Hiring Range: Greater New York City Area (NY, NJ, CT residents): $154,600 - $236,555. All other locations (within approved locations): $127,500 - $195,075. Salary and related compensation will be contingent upon work experience, education, licenses, and certifications. Healthfirst offers employees a full range of benefits such as medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401(k) contributions (subject to eligibility requirements).