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Director Payment Integrity - Coordination of Benefits

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Customer Service/Claims/Operations
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14754 Requisition #
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Role is responsible for the leadership, program management and management of the Coordination of Benefits (COB) function to ensure claims payment accuracy. The role is accountable for ensuring ongoing compliance with state and federal requirements. This role is responsible for day-to-day management of both the internal operational processes and staff, as well as all associated vendors processes; in addition, this position is accountable for oversight of IT solutions enabling internal and vendor business processes. Incumbent is accountable for ensuring timely and clear communication of key findings and outcomes to all impacted business partners, both internal and external, at a variety of leadership levels.

Job duties include but are not limited to:
• Ensure all COB-related operational processes and enabling technology, including all vendor solutions, are compliant with state and federal regulations, leveraging industry standard/best practices in the application of effective monitoring and controls to mitigate risk to the enterprise
• Design, implement and manage appropriate technological infrastructure and operational workflows to facilitate COB processes that utilize a more strategic, risk based approach to maximize value and ensure claims are paid correctly
• Lead and manage the COB organization in support of all lines of business, ensuring resources are secured to effectively manage internal operations/ inventory and oversight of vendors
• Develop and maintain processes to allow for effective oversight of enabling IT solutions, and integration with IT domains/teams, to ensure successful implementation of projects and timely resolution to issues
• Develop strategies and implement programs to continually improve COB processes, leveraging continuous improvement methodologies and/or vendor capabilities
• Manage COB vendor and related processes end-to-end, ensuring vendor performance management and contract compliance
• Develop capabilities to track and report COB performance to assess and achieve operational and vendor performance and goals, including the impact of COB processes on administrative and medical costs; develop communication strategies and procedures to ensure impacted internal and external stakeholders have the necessary awareness of COB outcomes in a proactive fashion
• Control administrative expenses through oversight of COB processes, vendors, managers and staff activities. Set budget expectations and take corrective action as necessary related to budget variances for internal staff as well as vendors
• Drive and ensure alignment between COB processes and other enterprise processes impacted by COB programs and process (e.g., claims, customer service, enrollment/billing, etc.)

Job Requirements:
• Bachelor’s degree or equivalent work experience • Bachelor’s Degree or equivalent work experience
• 6+ years related work experience or equivalent combination of transferable experience and education.
• Strong experience in the areas of coordination of benefits (COB)
• 3+ years direct supervisory/management experience
• Knowledge of COB standards and regulations set forth by the National Association of Insurance Commissioners (NAIC) and state and federal regulations, including but not limited to Section 111, Medicare Payment Demand, Medicare Secondary Payer Group Health Plan Requirements, workers compensation, PIP/accident
• Demonstrated ability to assemble teams and develop talent
• Strong communication skills
• Strong experience presenting and reporting outcomes to executive leadership
• Experience with IT capability development to drive and enable operational and vendor solutions
• Demonstrated ability to develop and implement innovative and creative strategies and encourage others to do the same

Preferred:
• Master’s degree
• Knowledge of the Blue Cross and Blue Shield business practices, rules and the BlueCard system
• Experience identifying, implementing, and overseeing vendor solutions

We are an Equal Opportunity Employer/Protected Veteran/Disabled.

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