Executive Director of Claims

THE ROLE

The Executive Director directs, manages and oversees the activities of the delegated claim operations including claim adjudication, processing encounter data, and maintenance of current eligibility and benefits information. Expectations include compliance with applicable Federal, State, health plan and contractual regulations and guidelines. The Executive Director Claims Operations interfaces with internal and external resources and departments to maintain current industry knowledge and participate effectively on process development efforts focused on achieving continuous improvement in operational efficiency, processing accuracy, and customer service performance.

ESSENTIAL FUNCTIONS

• Lead best-in-class liability claim organization responsible for managing all liability lines, including hospital professional liability, general liability, cyber liability, D&O, employers liability, and managed care, as well as for leveraging claim insight to provide feedback to partners across ministries and shared services to manage risk and identify emerging risks.


• This position leads leaders and is responsible for ensuring all leaders have appropriate development and training support to lead teams to deliver exceptional results.


• Ensure optimal claim model and strategies, including consistent enhancements, leveraging digital and data-driven strategies to drive efficient workflows and processes and support development of impactful claim insights.


• Ensure compliance with all relevant regulations, including state and federal reporting, and develop operational strategies to drive efficient, low touch and accurate reporting capabilities.


• Drive effective claim strategies, including effective management of pre-suit and litigated large loss and severity claims, including early and thorough assessment of issues, proper analysis and use of data, accountability, budget discipline, technical and professional development, trial acumen/appetite, and innovative and strategic use of resources.


• Ensure sound financial management practices, including effective reserving and settlement strategies to ensure reasonable outcomes and forecast exposure.


• Identify training needs and lead production of tailored training and development resources for claim professionals and leaders.


• Partner with shared services leaders and risk managers across the ministries to understand needs and support effective knowledge sharing and collaboration to manage risk.


• Develops, monitors and reports key measurements and trends to leadership.

QUALIFICATIONS

• Bachelor's Degree; or equivalent educ/experience


• Master's Degree, or J.D. (preferred)


• 10 or more years of experience with responsibilities in high-volume transaction processing, information interpretation, presentation and application to internal and inter-departmental efficiency. 


• 8 years of proven leadership ability to interact at and communicate to all levels of an organization. Organizational, interpersonal, and communications skills and the ability to manage shifting priorities are critical for success in this position


• Expertise includes delegated medical group functions, management and analysis


• Must possess excellent oral and written communication, and computer skills encompassing various software applications (database applications such as Access, data warehouse environment, Excel, Word, PowerPoint, etc.)


• Make effective presentations to communicate performance expectations, activities and results


• Working knowledge of change and transition management and the creation of programs and processes to maximize efficiency and support company goals through transitions


• Maintain effective and professional relationships with hospital and health plan partners


• Work in a collaborative and collegial manner to achieve continued enhancement and improvement of operating results.